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Zhang BC, Yang ZB, Liao RL, Ma ZQ, Zhang QJ, He QK, Duan XY, Liu MW. A case of scrub typhus with meningitis as the onset: Case report and literature review. Medicine (Baltimore) 2024; 103:e38613. [PMID: 38905360 PMCID: PMC11191975 DOI: 10.1097/md.0000000000038613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 05/27/2024] [Indexed: 06/23/2024] Open
Abstract
RATIONALE Scrub typhus is a naturally occurring acute febrile disease caused by Orientia tsutsugamushi. Although it can cause multiple organ dysfunction, central nervous system infections are uncommon. PATIENT CONCERNS A 17-year-old male presented with a 5-day history of fever and headaches. The MRI of the head revealed thickness and enhancement of the left temporal lobe and tentorium cerebelli, indicating potential inflammation. DIAGNOSES The patient was diagnosed with a central nervous system infection. INTERVENTIONS Ceftriaxone and acyclovir were administered intravenously to treat the infection, reduce fever, restore acid-base balance, and manage electrolyte disorders. OUTCOMES Despite receiving ceftriaxone and acyclovir as infection therapy, there was no improvement. Additional multipathogen metagenomic testing indicated the presence of O tsutsugamushi infection, and an eschar was identified in the left axilla. The diagnosis was changed to scrub typhus with meningitis and the therapy was modified to intravenous doxycycline. Following a 2-day therapy, the body temperature normalized, and the fever subsided. CONCLUSIONS The patient was diagnosed with scrub typhus accompanied by meningitis, and doxycycline treatment was effective. LESSION Rarely reported cases of scrub typhus with meningitis and the lack of identifiable symptoms increase the chance of misdiagnosis or oversight. Patients with central nervous system infections presenting with fever and headache unresponsive to conventional antibacterial and antiviral treatment should be considered for scrub typhus with meningitis. Prompt multipathogen metagenomic testing is recommended to confirm the diagnosis and modify the treatment accordingly.
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Affiliation(s)
- Bing-Can Zhang
- Department of Orthopedics, People’s Hospital of Dali Bai Autonomous Prefecture, Dali, Yunnan, China
| | - Zi-Bin Yang
- Department of Orthopedics, People’s Hospital of Dali Bai Autonomous Prefecture, Dali, Yunnan, China
| | - Ren-Li Liao
- Department of Orthopedics, People’s Hospital of Dali Bai Autonomous Prefecture, Dali, Yunnan, China
| | - Zhi-Qiang Ma
- Department of Clinical Laboratory, People’s Hospital of Dali Bai Autonomous Prefecture, Dali, Yunnan, China
| | - Qiu-Juan Zhang
- Department of Emergency, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Qian-Kun He
- Department of Neurology, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, China
| | - Xin-Ya Duan
- Department of Tuberculosis Diseases, Third People’s Hospital of Kunming City, Kunming, China
| | - Ming-Wei Liu
- Department of Emergency, The People's Hospital of Dali Bai Autonomous Prefecture, Dali, Yunnan, China
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Oakley R, Kann S, Concha G, Plag M, Poppert S, Graves S, Paris DH, Dreyfus A. Seroprevalence of Rickettsia Spp. and Orientia tsutsugamushi in Indigenous Populations from the Sierra Nevada de Santa Marta, Colombia. Vector Borne Zoonotic Dis 2024. [PMID: 38742967 DOI: 10.1089/vbz.2023.0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024] Open
Abstract
Background: Rickettsia spp. are vector-borne zoonotic pathogens that cause febrile illness in humans. Rickettsioses is not included in the Colombian national surveillance system and is subsequently expected to be underreported. This cross-sectional study aimed to determine the seroprevalence of Rickettsia spp. and the closely related Orientia tsutsugamushi in two indigenous populations residing in the Sierra Nevada de Santa Marta, Colombia. Materials and Methods: Serum samples (n = 539) were collected from the Wiwa and Koguis people between 2021 and 2022. Serum samples were screened for spotted fever group (SFG) and typhus group (TG) Rickettsia spp. using the Fuller laboratories Rickettsia IgG IFA kit and for O. tsutsugamushi with the Scrub Typhus Detect™ IgG ELISA. Results: We observed an overall seroprevalence of 26.2% (95% confidence interval [CI] 22.5-30.1] for Rickettsia spp. of the SFG, 5.4% (95% CI 3.6-7.6) for Rickettsia spp. of the TG and 4.3% (95% CI 2.7-6.3) for O. tsutsugamushi. Common risk factors for zoonotic disease infections were assessed for 147 of the Wiwa participants. Increased odds of seropositivity for SFG Rickettsia spp. were observed for Wiwa participants who cared for livestock, including assisting with the birth of cattle (odds ratio [OR] = 8.85; 95% CI 1.54-50.90; p = 0.015) and goats (OR = 7.60; 95% CI 1.70-33.90; p = 0.008). Conclusions: These results highlight a notable exposure to Rickettsia spp., especially the SFG, in rural Colombia. Together with recent reports of high mortality for Rocky Mountain Spotted Fever in nearby regions of South America, more detailed investigations focusing on improving knowledge and awareness as well as "One Health" and "causes-of-fever" studies are needed. The characterization of Rickettsia spp. infections in humans, livestock, and tick vectors with their potential transmission routes could make a high impact on these easily treatable diseases.
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Affiliation(s)
- Regina Oakley
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Gustavo Concha
- Organización Wiwa Yugumaiun Bunkuanarua Tairona, Valledupar, Colombia
| | - Michèle Plag
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Sven Poppert
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Stephen Graves
- Australian Rickettsial Reference Laboratory, Geelong, Australia
| | - Daniel H Paris
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Anou Dreyfus
- Vetsuisse Faculty, University of Zürich, Zürich, Switzerland
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3
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Jian H, Yang QX, Duan JX, Lai SY, Che GL, Teng J, Chang L, Liu XJ, Luo LL, Liu F. mNGS helped diagnose scrub typhus-associated HLH in children: a report of two cases. Front Public Health 2024; 12:1321123. [PMID: 38784570 PMCID: PMC11111966 DOI: 10.3389/fpubh.2024.1321123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 04/19/2024] [Indexed: 05/25/2024] Open
Abstract
Background Scrub typhus, caused by the Orientia tsutsugamushi (Ot), is a widespread vector-borne disease transmitted by chigger mites. Hemophagocytic lymphohistiocytosis (HLH) is considered to be one of the potentially severe complications. The diagnosis of scrub typhus-associated HLH may be overlooked due to the non-specific clinical characteristics and the absence of pathognomonic eschar. Case presentation We obtained clinical data from two patients in the South of Sichuan, China. The first case involved a 6-year-old girl who exhibited an unexplained fever and was initially diagnosed with sepsis, HLH, and pulmonary infection. The other patient presented a more severe condition characterized by multiple organ dysfunction and was initially diagnosed with septic shock, sepsis, HLH, acute kidney injury (AKI), and pulmonary infection. At first, a specific examination for scrub typhus was not performed due to the absence of a characteristic eschar. Conventional peripheral blood cultures yielded negative results in both patients, and neither of them responded to routine antibiotics. Fortunately, the causative pathogen Orientia tsutsugamushi (Ot) was detected in the plasma samples of both patients using metagenomics next-generation sequencing (mNGS) and further confirmed by polymerase chain reaction. Subsequently, they both were treated with doxycycline and recovered quickly. Conclusion The unbiased mNGS provided a clinically actionable diagnosis for an uncommon pathogen-associated infectious disease that had previously evaded conventional diagnostic approaches.
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Affiliation(s)
- Hui Jian
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Obstetric and Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, China
| | - Qiu-xia Yang
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Obstetric and Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, China
| | - Jia-xin Duan
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Obstetric and Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, China
| | - Shu-yu Lai
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Obstetric and Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, China
| | - Guang-lu Che
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Obstetric and Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, China
| | - Jie Teng
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Obstetric and Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, China
| | - Li Chang
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Obstetric and Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, China
| | - Xiao-juan Liu
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Obstetric and Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, China
| | - Li-li Luo
- Key Laboratory of Obstetric and Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, China
- Department of Pediatric Critical Care Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Fang Liu
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Obstetric and Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, China
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4
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Liang Y, Wang H, Sun K, Sun J, Soong L. Lack of the IFN-γ signal leads to lethal Orientia tsutsugamushi infection in mice with skin eschar lesions. PLoS Pathog 2024; 20:e1012020. [PMID: 38743761 PMCID: PMC11125519 DOI: 10.1371/journal.ppat.1012020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 05/24/2024] [Accepted: 04/30/2024] [Indexed: 05/16/2024] Open
Abstract
Scrub typhus is an acute febrile disease due to Orientia tsutsugamushi (Ot) infection and can be life-threatening with organ failure, hemorrhage, and fatality. Yet, little is known as to how the host reacts to Ot bacteria at early stages of infection; no reports have addressed the functional roles of type I versus type II interferon (IFN) responses in scrub typhus. In this study, we used comprehensive intradermal (i.d.) inoculation models and two clinically predominant Ot strains (Karp and Gilliam) to uncover early immune events. Karp infection induced sequential expression of Ifnb and Ifng in inflamed skin and draining lymph nodes at days 1 and 3 post-infection. Using double Ifnar1-/-Ifngr1-/- and Stat1-/- mice, we found that deficiency in IFN/STAT1 signaling resulted in lethal infection with profound pathology and skin eschar lesions, which resembled to human scrub typhus. Further analyses demonstrated that deficiency in IFN-γ, but not IFN-I, resulted in impaired NK cell and macrophage activation and uncontrolled bacterial growth and dissemination, leading to metabolic dysregulation, excessive inflammatory cell infiltration, and exacerbated tissue damage. NK cells were found to be the major cellular source of innate IFN-γ, contributing to the initial Ot control in the draining lymph nodes. In vitro studies with dendritic cell cultures revealed a superior antibacterial effect offered by IFN-γ than IFN-β. Comparative in vivo studies with Karp- and Gilliam-infection revealed a crucial role of IFN-γ signaling in protection against progression of eschar lesions and Ot infection lethality. Additionally, our i.d. mouse models of lethal infection with eschar lesions are promising tools for immunological study and vaccine development for scrub typhus.
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Affiliation(s)
- Yuejin Liang
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, Texas, United States of America
- Institute for Human Infections and Immunity, University of Texas Medical Branch, Galveston, Texas, United States of America
- Center for Tropical Diseases, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Hui Wang
- Institute for Human Infections and Immunity, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Pathology, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Keer Sun
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, Texas, United States of America
- Institute for Human Infections and Immunity, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Jiaren Sun
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, Texas, United States of America
- Institute for Human Infections and Immunity, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Pathology, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Lynn Soong
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, Texas, United States of America
- Institute for Human Infections and Immunity, University of Texas Medical Branch, Galveston, Texas, United States of America
- Center for Tropical Diseases, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Pathology, University of Texas Medical Branch, Galveston, Texas, United States of America
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5
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Jitvaropas R, Sawaswong V, Poovorawan Y, Auysawasdi N, Vuthitanachot V, Wongwairot S, Rodkvamtook W, Lindroth E, Payungporn S, Linsuwanon P. Identification of Bacteria and Viruses Associated with Patients with Acute Febrile Illness in Khon Kaen Province, Thailand. Viruses 2024; 16:630. [PMID: 38675971 PMCID: PMC11054472 DOI: 10.3390/v16040630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
The majority of cases of undifferentiated acute febrile illness (AFI) in the tropics have an undefined etiology. In Thailand, AFI accounts for two-thirds of illnesses reported to the Ministry of Public Health. To characterize the bacterial and viral causes of these AFIs, we conducted molecular pathogen screening and serological analyses in patients who sought treatment in Chum Phae Hospital, Khon Kaen province, during the period from 2015 to 2016. Through integrated approaches, we successfully identified the etiology in 25.5% of cases, with dengue virus infection being the most common cause, noted in 17% of the study population, followed by scrub typhus in 3.8% and rickettsioses in 6.8%. Further investigations targeting viruses in patients revealed the presence of Guadeloupe mosquito virus (GMV) in four patients without other pathogen co-infections. The characterization of four complete genome sequences of GMV amplified from AFI patients showed a 93-97% nucleotide sequence identity with GMV previously reported in mosquitoes. Nucleotide substitutions resulted in amino acid differences between GMV amplified from AFI patients and mosquitoes, observed in 37 positions. However, these changes had undergone purifying selection pressure and potentially had a minimal impact on protein function. Our study suggests that the GMV strains identified in the AFI patients are relatively similar to those previously reported in mosquitoes, highlighting their potential role associated with febrile illness.
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Affiliation(s)
- Rungrat Jitvaropas
- Division of Biochemistry, Department of Preclinical Science, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand;
| | - Vorthon Sawaswong
- Center of Excellence in Systems Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand;
| | - Yong Poovorawan
- Center of Excellence in Clinical Virology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand;
| | - Nutthanun Auysawasdi
- Department of Entomology, US Medical Directorate-Armed Forces Research Institute of Medical Science, Bangkok 10400, Thailand; (N.A.); (S.W.); (E.L.)
| | | | - Sirima Wongwairot
- Department of Entomology, US Medical Directorate-Armed Forces Research Institute of Medical Science, Bangkok 10400, Thailand; (N.A.); (S.W.); (E.L.)
| | - Wuttikon Rodkvamtook
- Analytic Division, Royal Thai Army Component-Armed Forces Research Institute of Medical Science, Bangkok 10400, Thailand;
| | - Erica Lindroth
- Department of Entomology, US Medical Directorate-Armed Forces Research Institute of Medical Science, Bangkok 10400, Thailand; (N.A.); (S.W.); (E.L.)
| | - Sunchai Payungporn
- Center of Excellence in Systems Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand;
- Department of Biochemistry, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Piyada Linsuwanon
- Department of Entomology, US Medical Directorate-Armed Forces Research Institute of Medical Science, Bangkok 10400, Thailand; (N.A.); (S.W.); (E.L.)
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6
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Jain HK, Das A, Dixit S, Kaur H, Pati S, Ranjit M, Dutta A, Bal M. Development and implementation of a strategy for early diagnosis and management of scrub typhus: an emerging public health threat. Front Public Health 2024; 12:1347183. [PMID: 38660358 PMCID: PMC11039949 DOI: 10.3389/fpubh.2024.1347183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 03/21/2024] [Indexed: 04/26/2024] Open
Abstract
Scrub typhus, caused by Orientia tsutsugamushi, is a re-emerging zoonotic disease in the tropics with considerable morbidity and mortality rates. This disease, which is mostly prevalent in rural areas, remains underdiagnosed and underreported because of the low index of suspicion and non-specific clinical presentation. Limited access to healthcare, diagnostics, and treatment in rural settings further makes it challenging to distinguish it from other febrile illnesses. While easily treatable, improper treatment leads to severe forms of the disease and even death. As there is no existing public health program to address scrub typhus in India, there is an urgent need to design a program and test its effectiveness for control and management of the disease. With this backdrop, this implementation research protocol has been developed for a trial in few of the endemic "pockets" of Odisha, an eastern Indian state that can be scalable to other endemic areas of the country, if found effective. The main goal of the proposed project is to include scrub typhus as a differential diagnosis of fever cases in every tier of the public health system, starting from the community level to the health system, for the early diagnosis among suspected cases and to ensure that individuals receive complete treatment. The current study aimed to describe the protocol of the proposed Scrub Typhus Control Program (STCP) in detail so that it can receive valuable views from peers which can further strengthen the attempt.
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Affiliation(s)
- Hitesh Kumar Jain
- Department of Molecular Epidemiology, Indian Council of Medical Research, Regional Medical Research Centre, Bhubaneswar, India
| | - Arundhuti Das
- Department of Molecular Epidemiology, Indian Council of Medical Research, Regional Medical Research Centre, Bhubaneswar, India
| | - Sujata Dixit
- Department of Molecular Epidemiology, Indian Council of Medical Research, Regional Medical Research Centre, Bhubaneswar, India
| | - Harpreet Kaur
- Department of Epidemiology and Communicable Diseases, Indian Council of Medical Research, New Delhi, India
| | - Sanghamitra Pati
- Department of Public Health, Indian Council of Medical Research, Regional Medical Research Centre, Bhubaneswar, India
| | - Manoranjan Ranjit
- Department of Molecular Epidemiology, Indian Council of Medical Research, Regional Medical Research Centre, Bhubaneswar, India
| | - Ambarish Dutta
- Department of Epidemiology, Public Health Foundation of India, Indian Institute of Public Health, Bhubaneswar, India
| | - Madhusmita Bal
- Department of Molecular Epidemiology, Indian Council of Medical Research, Regional Medical Research Centre, Bhubaneswar, India
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Selvan AT, Agarwal I, Behera B, Singh S. Scrub typhus in pregnancy: A report of two cases. Obstet Med 2024; 17:58-60. [PMID: 38660322 PMCID: PMC11037195 DOI: 10.1177/1753495x221122593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/27/2022] [Indexed: 04/26/2024] Open
Abstract
Scrub typhus shows a high prevalence in South-East Asia. In pregnant females, it can cause both maternal and fetal adverse outcomes. We report a case series of two women with scrub typhus and their varied outcomes. A 25-year-old primigravida treated for scrub typhus at 23 weeks' gestation presented at 34 weeks with stage three fetal growth restriction (FGR). Caesarean delivery was performed. The neonate had biliary atresia. A 24-year-old primigravida at 31 weeks' gestation was referred from a local hospital due to scrub typhus induced multi-organ dysfunction. She had FGR stage 1 with oligohydramnios. Emergency caesarean delivery was performed in view of acute fetal bradycardia. There is an emerging need for research to reassess what is already known about scrub typhus in pregnancy and to develop techniques for its treatment inorder to achieve a positive maternal and neonatal outcome in these cases.
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Affiliation(s)
- Advika Thamarai Selvan
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Ishita Agarwal
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Bijayini Behera
- Department of Microbiology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Sweta Singh
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Bhubaneswar, India
- Trialect Fellow (High Risk Pregnancy), King’s College Hospital, London, UK
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8
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He J, Ma Q, Teng Z, Zhou J, Zhao N, Liang W, Lu M, Li S, Qin T. Epidemiological and clinical characteristics of scrub typhus in Guizhou Province, China: An outbreak study of scrub typhus. PLoS Negl Trop Dis 2024; 18:e0011963. [PMID: 38442086 PMCID: PMC10914282 DOI: 10.1371/journal.pntd.0011963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 02/02/2024] [Indexed: 03/07/2024] Open
Abstract
The reported cases of scrub typhus (ST) have continued to escalate, with outbreaks occurring regionally in China. These pose an increasing public health threat at a time when public health has been overwhelmed. During the period from July to August 2022, in Rongjiang County, Guizhou Province, China, 13 out of 21 fever patients were diagnosed with scrub typhus, based on epidemiological investigation and blood test analysis. The major clinical symptoms of these patients showed fever, chills, headache, eschar, fatigue and pneumonia, which were accompanied by a rise in C-reactive protein, neutrophils, alanine transaminase (ALT) and aspartate aminotransferase (AST). Furthermore, nearly half of them exhibited abnormal electrocardiogram activity. Through semi-nested PCR, Sanger sequencing and phylogenetic tree construction, the Karp strain of Orientia tsutsugamushi (O. tsutsugamushi) was confirmed as the pathogen causing ST in Rongjiang County, which shared the same evolutionary branch with O. tsutsugamushi isolated from wild mouse liver or spleen, indicating that the wild mouse plays an important role in transmitting the disease. In contrast to the sporadic cases in the past, our study is the first to disclose an epidemic and the corresponding clinical characteristics of ST in Guizhou province, which is of great significance for the prevention and treatment of regional illnesses.
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Affiliation(s)
- Jia He
- National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, People’s Republic of China
| | - Qing Ma
- Guizhou Center for Disease Control and Prevention, Guizhou, People’s Republic of China
| | - Zhongqiu Teng
- National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, People’s Republic of China
| | - Jingzhu Zhou
- Guizhou Center for Disease Control and Prevention, Guizhou, People’s Republic of China
| | - Na Zhao
- National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, People’s Republic of China
| | - Wenqin Liang
- Guizhou Center for Disease Control and Prevention, Guizhou, People’s Republic of China
| | - Miao Lu
- National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, People’s Republic of China
| | - Shijun Li
- Guizhou Center for Disease Control and Prevention, Guizhou, People’s Republic of China
| | - Tian Qin
- National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, People’s Republic of China
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9
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Han S, Yang S, Wang Y, Xu Y. Case Report: Encephalitis with Initial Manifestation of Orientia Tsutsugamushi Infection Detected by Metagenomic Next-Generation Sequencing. Infect Drug Resist 2024; 17:749-760. [PMID: 38433784 PMCID: PMC10906725 DOI: 10.2147/idr.s450693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/07/2024] [Indexed: 03/05/2024] Open
Abstract
Purpose Scrub typhus, caused by Orientia tsutsugamushi, is characterized by fever, eschars, lymphadenopathy, and rash. The absence of eschars in some cases makes it difficult to distinguish it from other diseases, complicating the diagnosis process. Atypical Scrub typhus is difficult to diagnose and often leads to delayed treatment. Therefore, early diagnosis and treatment through effective detection methods have high clinical value. Here, a case of scrub typhus with encephalitis symptoms is reported. Patients and Methods A 64-year-old man and mNGS testing. Results A 64-year-old man developed cough, headache, and fever, dismissing it as a respiratory tract infection. Initial treatment with cephalosporin antibiotics had minimal effect. Admission to the respiratory department showed inflammation in blood tests. Subsequent CT and further treatment provided no improvement. Multidisciplinary discussions and neurology department guidance were conducted to consider the suspected diagnosis of encephalitis in the patient. After improving the mNGS detection, the patient was diagnosed with "Orientia tsutsugamushi encephalitis". After treatment with doxycycline, the patient's symptoms were alleviated. He remained afebrile in follow-up and adhered well to medical advice. Conclusion Our case demonstrates that it is difficult to distinguish Orientia tsutsugamushi encephalitis from central nervous system infectious diseases such as meningitis and encephalitis using conventional diagnostic methods, which may affect the treatment plan for the disease. mNGS is a useful and valuable method for early diagnosis of scrub typhus.
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Affiliation(s)
- Song Han
- The Second Hospital of Shandong University, Cheeloo College of Medicine of Shandong University, Shandong University, Jinan, 250033, People’s Republic of China
| | - Suge Yang
- The Second Hospital of Shandong University, Cheeloo College of Medicine of Shandong University, Shandong University, Jinan, 250033, People’s Republic of China
| | - Yun Wang
- Department of Neurology Medicine, The Second Hospital of Shandong University, Cheeloo College of Medicine of Shandong University, Shandong University, Jinan, 250033, People’s Republic of China
| | - Yingying Xu
- Department of Neurology Medicine, The Second Hospital of Shandong University, Cheeloo College of Medicine of Shandong University, Shandong University, Jinan, 250033, People’s Republic of China
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Yang X, Zhang L, Chen S, Chen W, Zhang Y, Zhang Y, Liang J, Lv Y, Wang W, Zhou Y, Huang R, Pan D, Li X, Li Q. A case of neonatal tsutsugamushi disease diagnosed with the aid of rickettsial macrogenomic detection. BMC Pediatr 2024; 24:90. [PMID: 38302958 PMCID: PMC10835854 DOI: 10.1186/s12887-024-04561-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 01/12/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND Tsutsugamushi, also known as bush typhus, is a naturally occurring disease caused by Orientia tsutsugamushi. We reported a case of vertical mother-to-newborn transmission of Orientia tsutsugamushi infection in a newborn from Yunnan (China). CASE PRESENTATION Decreased fetal movements were observed at 39 weeks of gestation. After birth, the newborn (female) had recurrent fever, shortness of breath, and bruising around the mouth and extremities. At 5 h 58 min of age, the newborn was admitted for fever, shortness of breath and generalized rash. The liver was palpable 3 cm below the costal margin, and the limbs showed pitting edema. There was subcutaneous bleeding. Investigations suggested heavy infection, myocardial damage, decreased platelets. Treatment with cefotaxime and ampicillin failed. The mother was hospitalized at 29 weeks of gestation with a fever for 4 consecutive days, and an ulcerated crust was found in the popliteal fossa. Due to this pregnancy history, A diagnosis of Orientia tsutsugamushi infection was suspected in our index case and confirmed by macrogenomic testing and she was treated with vancomycin and meropenem, and later azithromycin for 1 week. The newborn was discharged in good general condition, gradually normalizing body temperature, and decreasing rash and jaundice. There were no abnormalities on subsequent blood macrogenomic tests for the baby. And one month later she showed good mental health, sleep, and food intake and no fever, rash, or jaundice. CONCLUSION Determining the cause of symptoms is the key to treating diseases, especially the rare diseases that can be misdiagnosed. SUITABLE FOR PEOPLE WITH Infectious Diseases; Neonatology; Obstetrics.
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Affiliation(s)
- Xu Yang
- Department of Paediatrics, Pu'er People's Hospital, Pu'er, 665000, China.
| | - Ling Zhang
- Department of Paediatrics, Pu'er People's Hospital, Pu'er, 665000, China
| | - Shanping Chen
- Department of Paediatrics, Pu'er People's Hospital, Pu'er, 665000, China
| | - Wei Chen
- Department of Infectious Diseases, Pu'er People's Hospital, Pu'er, 665000, China
| | - Yushan Zhang
- Department of Paediatrics, Pu'er People's Hospital, Pu'er, 665000, China
| | - Yi Zhang
- Department of Paediatrics, Pu'er People's Hospital, Pu'er, 665000, China
| | - Jialong Liang
- General Practice, Pu'er People's Hospital, Pu'er, 665000, China
| | - Ying Lv
- Department of Paediatrics, Pu'er People's Hospital, Pu'er, 665000, China
| | - Weiyan Wang
- Department of Anesthesiology, Pu'er People's Hospital, Pu'er, 665000, China
| | - Yini Zhou
- Department of Paediatrics, Pu'er People's Hospital, Pu'er, 665000, China
| | - Rui Huang
- Department of Paediatrics, Pu'er People's Hospital, Pu'er, 665000, China
| | - Dongju Pan
- Department of Paediatrics, Pu'er People's Hospital, Pu'er, 665000, China
| | - Xueyu Li
- Department of Paediatrics, Pu'er People's Hospital, Pu'er, 665000, China
| | - Qiurong Li
- Department of Paediatrics, Pu'er People's Hospital, Pu'er, 665000, China
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Govindarajan R, Sankar SG, Kumar MS, Rajamannar V, Krishnamoorthi R, Anand AAP, Kumar A, Samuel PP. Molecular detection of Orientia tsutsugamushi in ectoparasites & their small mammal hosts captured from scrub typhus endemic areas in Madurai district, India. Indian J Med Res 2024; 159:180-192. [PMID: 38494626 PMCID: PMC11050748 DOI: 10.4103/ijmr.ijmr_3530_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND OBJECTIVES Scrub typhus, caused by Orientia tsutsugamushi present in small mammals harbouring the ectoparasites. A study was undertaken to detect the pathogen present in small mammals and its ectoparasites in the scrub typhus-reported areas. METHODS The small mammals (rodents/shrews) and its ectoparasites were screened for O. tsutsugamushi using nested PCR amplification of the groEL gene. Small mammals were collected by trapping and screened for ectoparasites (mites, ticks and fleas) by combing method. RESULTS All the chigger mites collected were tested negative for O. tsutsugamushi . Interestingly, adult non-trombiculid mites ( Oribatida sp., Dermanyssus gallinae ), fleas ( Xenopsylla astia, X. cheopis, Ctenophalides felis and Ctenophalides sp.) and ticks ( Rhipicephalus sanguineus , R. haemaphysaloides ) screened were found to be positive for O. tsutsugamushi , which the authors believe is the first report on these species globally. Bandicota bengalensis with O. tsutsugamushi infection is reported for the first time in India. The O. tsutsugamushi groEL sequences from the positive samples were similar to the reference strains, Karp and Ikeda and phylogenetically clustered in clade IV with less evolutionary divergence. The blood samples of Rattus rattus , Suncus murinus and B. bengalensis collected from this area were tested positive for O. tsutsugamushi ; interestingly, the sequence similarity was much pronounced with their ectoparasites indicating the transmission of the pathogen to host or vice versa . INTERPRETATION CONCLUSIONS The outcome of the present investigations widened our scope on the pathogens present in ectoparasites and rodents/shrews from this area. This will help to formulate the required vector control methods to combat zoonotic diseases.
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Affiliation(s)
- R. Govindarajan
- Division of Vector Borne Zoonotic Diseases, ICMR-Vector Control Research Centre Field Station, Madurai, Tamil Nadu, India
| | - S. Gowri Sankar
- Division of Vector Borne Zoonotic Diseases, ICMR-Vector Control Research Centre Field Station, Madurai, Tamil Nadu, India
| | - M. Senthil Kumar
- Division of Vector Borne Zoonotic Diseases, ICMR-Vector Control Research Centre Field Station, Madurai, Tamil Nadu, India
| | - V. Rajamannar
- Division of Vector Borne Zoonotic Diseases, ICMR-Vector Control Research Centre Field Station, Madurai, Tamil Nadu, India
| | | | | | - Ashwani Kumar
- ICMR-Vector Control Research Centre, Puducherry, India
| | - P. Philip Samuel
- Division of Vector Borne Zoonotic Diseases, ICMR-Vector Control Research Centre Field Station, Madurai, Tamil Nadu, India
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12
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D'Cruz S, Sreedevi K, Lynette C, Gunasekaran K, Prakash JAJ. Climate influences scrub typhus occurrence in Vellore, Tamil Nadu, India: analysis of a 15-year dataset. Sci Rep 2024; 14:1532. [PMID: 38233417 PMCID: PMC10794692 DOI: 10.1038/s41598-023-49333-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/07/2023] [Indexed: 01/19/2024] Open
Abstract
Climate is one of the major factors determining the prevalence and seasonality of vector borne diseases like scrub typhus (ST). We analyzed, the association of the meteorological factors like temperature, rainfall and humidity with scrub typhus using the 15 years scrub typhus data from a tertiary care hospital in Vellore, South India. Demographic data of permanent residents of Vellore, who had IgM ELISA results for scrub typhus for the time period of May 2005 to April 2020 were included. Meteorological data was correlated with the monthly scrub typhus cases; negative binomial regression model was used to predict the relation between scrub typhus occurrence and climate factors. Maximum number of ST cases were reported between the months August and February with October recording the highest number of cases. Elderly people, farmers, agricultural workers and housewives were at higher risk for scrub typhus. For an increase of 1 °C in mean temperature, the monthly ST cases reduced by 18.8% (95% CI - 24.1, - 13.2%). On the contrary, for 1 percent increase in mean relative humidity (RH), there is an increase of 7.6% (95% CI 5.4, 9.9%) of monthly ST cases. Similarly, an increase of 1 mm of rainfall contributed to 0.5 to 0.7% of monthly ST cases (after 2 months) depending on the variables included in the analysis. This study provides information that meteorological factors influence ST occurrence in Vellore. The rise of scrub typhus cases is maximal 2 months post rainfall. Whereas a rise in relative humidity, causes a rise in scrub typhus cases in same month, while rise in temperature has a negative impact on scrub typhus during the same month. These findings based on a retrospective analysis need validation by prospective studies.
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Affiliation(s)
- Solomon D'Cruz
- Department of Clinical Microbiology, Christian Medical College, Vellore, India
| | - Kotamreddy Sreedevi
- Department of Clinical Microbiology, Christian Medical College, Vellore, India
| | - Cheryl Lynette
- Department of Clinical Microbiology, Christian Medical College, Vellore, India
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Du Q, Zeng H, Pang X, Cao J, Xie B, Long C, Liang L, Deng F, Huang M, Li L, Huang F, Liu X, Hu Y, Lv J. CagA-positive Helicobacter pylori may promote and aggravate scrub typhus. Front Microbiol 2024; 15:1351784. [PMID: 38298891 PMCID: PMC10828044 DOI: 10.3389/fmicb.2024.1351784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 01/05/2024] [Indexed: 02/02/2024] Open
Abstract
Helicobacter pylori (H. pylori) infection may alter the host's resistance to tsutsugamushi disease pathogens through the Th1 immune response, leading to potential synergistic pathogenic effects. A total of 117 scrub typhus cases at Beihai People's Hospital and affiliated hospitals of Youjiang University for Nationalities and Medical Sciences were studied from January to December 2022, alongside 130 healthy individuals forming the control group. All participants underwent serum H. pylori antibody testing. The prevalence of H. pylori infection was significantly higher among scrub typhus patients (89.7%) compared to healthy individuals (54.6%) (p < 0.05). Moreover, type I H. pylori infection was notably more prevalent in scrub typhus cases (67.5%) compared to healthy individuals (30%) (p < 0.05). Multifactorial analysis demonstrated type I H. pylori infection as an independent risk factor for scrub typhus (adjusted odds ratio: 2.407, 95% confidence interval: 1.249-4.64, p = 0.009). Among scrub typhus patients with multiple organ damage, the prevalence of type I H. pylori infection was significantly higher (50.6%) than type II H. pylori infection (15.4%) (χ2 = 4.735, p = 0.030). These results highlight a higher incidence of H. pylori infection in scrub typhus patients compared to the healthy population. Additionally, type I H. pylori strain emerged as an independent risk factor for scrub typhus development. Moreover, individuals infected with type I H. pylori are more susceptible to multiple organ damage. These findings suggest a potential role of H. pylori carrying the CagA gene in promoting and exacerbating scrub typhus.
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Affiliation(s)
- Qiuying Du
- Department of Infectious Diseases, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Houyang Zeng
- Department of Infectious Diseases, Beihai People's Hospital, Beihai, Guangxi, China
| | - Xianwu Pang
- Guangxi Zhuang Autonomous Region Center for Disease Control and Prevention, Nanning, Guangxi, China
| | - Jianyu Cao
- Department of Infectious Diseases, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Bo Xie
- Institute of Life Sciences, Guangxi Medical University, Nanning, Guangxi, China
| | - Chunyi Long
- Department of Infectious Diseases, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Liudan Liang
- Department of Infectious Diseases, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Fenglian Deng
- Department of Infectious Diseases, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Meijin Huang
- Department of Infectious Diseases, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Li Li
- Department of Infectious Diseases, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Fengyan Huang
- Department of Infectious Diseases, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Xinli Liu
- Center for Genomic and Personalized Medicine, Guangxi key Laboratory for Genomic and Personalized Medicine, Guangxi Collaborative Innovation Center for Genomic and Personalized Medicine, Guangxi Medical University, Nanning, Guangxi, China
| | - Yanling Hu
- Institute of Life Sciences, Guangxi Medical University, Nanning, Guangxi, China
- Center for Genomic and Personalized Medicine, Guangxi key Laboratory for Genomic and Personalized Medicine, Guangxi Collaborative Innovation Center for Genomic and Personalized Medicine, Guangxi Medical University, Nanning, Guangxi, China
| | - Jiannan Lv
- Department of Infectious Diseases, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, Guangxi, China
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14
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Sharma A, Mahajan V, Guglani V, Singla N, Saini SS. Open-labeled Randomized Controlled Trial on Efficacy of Azithromycin Versus Doxycycline in Pediatric Scrub Typhus. Pediatr Infect Dis J 2023; 42:1067-1072. [PMID: 37773623 DOI: 10.1097/inf.0000000000004104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
BACKGROUND Doxycycline (DX) is the first-line therapeutic agent for scrub typhus. Macrolides, especially azithromycin (AZ), have been found to be equally efficacious as DX for treating scrub typhus in adults. We conducted this study to compare the efficacy of AZ versus DX in pediatric scrub typhus. STUDY DESIGN Open-label randomized controlled trial. METHODS Children 1-14 years of age suffering from acute febrile illness of ≥5 days and with a positive scrub IgM serology were randomized to receive either DX (2.2 mg/kg/dose twice daily in <40 kg; 100 mg BD in >40 kg for 7 days) or AZ (10 mg/kg/day for 5 days). The primary outcome was defervescence within 7 days of DX or 5 days of AZ. RESULTS We had 75 children randomized and analyzed using an intention-to-treat approach and 60 children analyzed via per-protocol analysis. The proportion of children achieving defervescence was comparable in 2 groups [per-protocol analysis: 90.9% in the DX group vs. 96.3% in the AZ group, RR: 0.94 (95% CI: 0.83-1.08)]. On Kaplan-Meier curves, AZ showed a significantly higher probability of defervescence at any time point during treatment as compared with DX (log-rank test P value 0.035). CONCLUSION AZ and DX had comparable rates of defervescence among children with scrub typhus. Trial registration No.: CTRI/2020/01/022991.
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Affiliation(s)
- Anjali Sharma
- From the Department of Pediatrics, Government Medical College and Hospital, Chandigarh, India
| | - Vidushi Mahajan
- From the Department of Pediatrics, Government Medical College and Hospital, Chandigarh, India
| | - Vishal Guglani
- From the Department of Pediatrics, Government Medical College and Hospital, Chandigarh, India
| | - Nidhi Singla
- From the Department of Pediatrics, Government Medical College and Hospital, Chandigarh, India
| | - Shiv Sajan Saini
- Department of Pediatrics, Neonatology Division, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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15
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Byeon JY, Kim H, Lee DW, Choi HJ. A CARE-compliant article: A case report of unusual eschar and extensive soft tissue necrosis in Tsutsugamushi disease. Medicine (Baltimore) 2023; 102:e36009. [PMID: 37960796 PMCID: PMC10637407 DOI: 10.1097/md.0000000000036009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/18/2023] [Indexed: 11/15/2023] Open
Abstract
RATIONALE Tsutsugamushi disease is a common infectious disease in the Northern Hemisphere. A patient infected with tsutsugamushi disease will show a characteristic clinical course with eschar formation, which is mostly small and self-limited in nature without causing major problems. We report a rare case of unusually extensive necrosis started from a small eschar. PATIENT CONCERNS In this report, a 65-year-old female patient with a history of diabetes mellitus present an 8 × 6 cm-sized huge eschar and extensive soft tissue necrosis aggravated from a small eschar. Also, there were 3 other small eschars in the scalp and left flank area. In early July, she was farming in a field in Hongseong-gun, South Korea. She had been treated at another hospital for 2 weeks. However, the eschar became bigger and worse. DIAGNOSES After admission, escharectomy was performed and extensive soft tissue necrosis was identified. Orientia tsutsugamushi antibody tests were positive from blood test. Providencia rettgeri and Enterococcus faecalis were detected in a tissue bacterial culture test. INTERVENTION While using oral azithromycin and intravenous imipenem/cilastatin, the necrosis of the thigh was excised and covered by lateral femoral circumflex artery based myocutaneous Keystone flap. OUTCOMES The remaining small eschars recovered spontaneously, the large eschars that had caused necrosis were successfully treated, and all other clinical symptoms improved without complications. LESSONS For unusual eschar of an unknown cause, especially in patients with uncontrolled diabetes or immunocompromised, the possibility of Tsutsugamushi should be considered. Careful physical examination and proper management should be performed as soon as possible.
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Affiliation(s)
- Je Yeon Byeon
- Department of Plastic and Reconstructive Surgery, College of Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, South Korea
| | - Hyun Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, South Korea
| | - Da Woon Lee
- Department of Plastic and Reconstructive Surgery, College of Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, South Korea
| | - Hwan Jun Choi
- Department of Plastic and Reconstructive Surgery, College of Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, South Korea
- Institute of Tissue Regeneration, College of Medicine, Soonchunhyang University, Cheonan, South Korea
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Vanramliana, Pautu L, Lalmalsawma P, Rosangkima G, Sarma DK, Chinzah H, Malvi Y, Kodali NK, Amarthaluri C, Balasubramani K, Balabaskaran Nina P. Epidemiology of scrub typhus and other rickettsial infections (2018-22) in the hyper-endemic setting of Mizoram, North-East India. PLoS Negl Trop Dis 2023; 17:e0011688. [PMID: 37910591 PMCID: PMC10642901 DOI: 10.1371/journal.pntd.0011688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 11/13/2023] [Accepted: 09/27/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND In the past decade, scrub typhus cases have been reported across India, even in regions that had no previous history of the disease. In the North-East Indian state of Mizoram, scrub typhus cases were first recorded only in 2012. However, in the last five years, the state has seen a substantial increase in the scrub typhus and other rickettsial infections. As part of the public health response, the Mizoram Government has integrated screening and line listing of scrub typhus and other rickettsial infections across all its health settings, a first in India. Here we detail the epidemiology of scrub typhus and other rickettsial infections from 2018-2022, systematically recorded across the state of Mizoram. METHODOLOGY/PRINCIPAL FINDINGS The line-listed data positive for scrub typhus and other rickettsial infections identified by rapid immunochromatographic test and/or Weil-Felix test from 2018-22 was used for the analysis. During this period, 22,914 cases of rickettsial infections were recorded, out of which 19,651 were scrub typhus cases. Aizawl is the worst affected, with 10,580 cases (46.17%). The average incidence of rickettsial infections is 3.54 cases per 1000 persons-year, and the case fatality rate is 0.35. Only ∼2% of the reported scrub typhus cases had eschar. Multivariate logistic regression analysis indicate patients with eschar (aOR = 2.5, p<0.05), occupational workers [farmers (aOR:3.9), businessmen (aOR:1.8), construction workers (aOR:17.9); p<0.05], and children (≤10 years) (aOR = 5.4, p<0.05) have higher odds of death due to rickettsial infections. CONCLUSION The integration of systematic surveillance and recording of rickettsial diseases across Mizoram has shed important insights into their prevalence, morbidity, and mortality. This study underscores the importance of active surveillance of rickettsial infections across India, as the burden could be substantially higher, and is probably going undetected.
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Affiliation(s)
- Vanramliana
- Department of Life Sciences, Pachhunga University College, Mizoram University, Mizoram, India
| | - Lalfakzuala Pautu
- Department of Life Sciences, Pachhunga University College, Mizoram University, Mizoram, India
- Integrated Disease Surveillance Programme, Health & Family Welfare Department, Mizoram, India
| | - Pachuau Lalmalsawma
- Integrated Disease Surveillance Programme, Health & Family Welfare Department, Mizoram, India
| | - Gabriel Rosangkima
- Department of Life Sciences, Pachhunga University College, Mizoram University, Mizoram, India
| | - Devojit Kumar Sarma
- ICMR- National Institute for Research in Environmental Health, Bhopal Bypass Road, Bhauri, Bhopal, Madhya Pradesh, India
| | - Hunropuia Chinzah
- Department of Life Sciences, Pachhunga University College, Mizoram University, Mizoram, India
| | - Yogesh Malvi
- Integrated Disease Surveillance Programme, Health & Family Welfare Department, Mizoram, India
| | - Naveen Kumar Kodali
- Department of Epidemiology and Public Health, Central University of Tamil Nadu, Thiruvarur, Tamil Nadu, India
| | - Christiana Amarthaluri
- Department of Public Health and Community Medicine, Central University of Kerala, Kasaragod, Kerala, India
| | | | - Praveen Balabaskaran Nina
- Department of Epidemiology and Public Health, Central University of Tamil Nadu, Thiruvarur, Tamil Nadu, India
- Department of Public Health and Community Medicine, Central University of Kerala, Kasaragod, Kerala, India
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Chen Z, OuYang S. Three cases of scrub typhus with hemorrhage: a case report and literature review. J Int Med Res 2023; 51:3000605231204430. [PMID: 37890141 PMCID: PMC10612463 DOI: 10.1177/03000605231204430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/13/2023] [Indexed: 10/29/2023] Open
Abstract
Scrub typhus (ST) is an acute focal infectious disease that is caused by Orientia tsutsugamushi. The Asia-Pacific region is an area of relatively high incidence. There is a high incidence in China, principally owing to the disease being endemic in the south of the country. The main source of ST infection is rats, which act as reservoirs of infection after being bitten by the chigger mite, and the human population is generally susceptible to the disease. ST can be controlled and treated successfully if antibiotics are administered in a timely manner. However, because it does not have a specific clinical manifestation, it is difficult to distinguish ST from other febrile diseases in clinical practice. Therefore, rapid diagnostic methods are still needed to help clinicians make a timely diagnosis. Here, we share three cases of patients with ST who experienced hemorrhage, but did not have typical skin lesions, such as eschar and ulcer, early in the course of their disease, and review the relevant literature regarding ST. We conclude that clinicians should pay attention to the risk of hemorrhage associated with this disease, and emphasize the importance of making an early diagnosis.
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Affiliation(s)
- Ziren Chen
- Department of Infectious Diseases, Key Laboratory of Biological Targeting Diagnosis, Therapy, and Rehabilitation of the Guangdong Higher Education Institutes, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Shi OuYang
- Department of Infectious Diseases, Key Laboratory of Biological Targeting Diagnosis, Therapy, and Rehabilitation of the Guangdong Higher Education Institutes, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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18
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Lamichhane P, Pokhrel KM, Alghalyini B, Zaidi ARZ, Alshehery MZ, Khanal K, Bhattarai M, Yadav A. Epidemiology, clinical characteristics, diagnosis, and complications of scrub typhus infection in Nepal: a systematic review. Ann Med Surg (Lond) 2023; 85:5022-5030. [PMID: 37811079 PMCID: PMC10553080 DOI: 10.1097/ms9.0000000000001259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 08/23/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction Scrub typhus (ST) is a neglected tropical disease of serious concern in Nepal. This systematic review aims to describe the burden of disease, clinical presentation, and complications of ST infection in Nepal. Methods A systematic search of PubMed, EMBASE, Google Scholar, and national databases was conducted for any literature published in English between January 2000 and January 2023. Any type of study design (observational studies, case series, and interventional studies) that reported laboratory-confirmed ST and was conducted in Nepal among patients of all age groups was included. The seroprevalence of ST among acute undifferentiated febrile illness (AUFI) cases, geographical distribution, monthly distribution, clinical presentations, complications, and treatment were assessed by the study. Result A total of 15 studies with 10, 977 participants were included in the review. The seroprevalence of ST among the AUFI cases in Nepal was 19.31%. Young people at or below 20 years of age were mostly affected. The maximum number of cases were reported from Bagmati province (59.46%) and in the month of August (26.33%). Fever, headache, cough, shortness of breath, nausea, and abdominal pain were the clinical characteristics in decreasing order of occurrence. The most common complication was acute kidney injury, followed by respiratory problems, cardiac issues, and neurological manifestations. The case fatality rate of ST in Nepal was 2.56%. Conclusion The authors findings showed a significant burden of ST among AUFI cases in Nepal. Improved surveillance, general public awareness, and early detection post-calamities could help reduce the disease burden and improve patient outcomes.
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Affiliation(s)
| | | | - Baraa Alghalyini
- Department of Family and Community Medicine, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Abdul Rehman Zia Zaidi
- Department of Family and Community Medicine, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Maied Z. Alshehery
- Department of Palliative Care, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Kapil Khanal
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
| | - Madhur Bhattarai
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
| | - Alisha Yadav
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
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19
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Kumar Jana J, Krishna Mandal A, Gayen S, Mahata D, Alam Mallick MS. Scrub Typhus in Children: A Prospective Observational Study in a Tertiary Care Hospital in Eastern India. Cureus 2023; 15:e41976. [PMID: 37593313 PMCID: PMC10427745 DOI: 10.7759/cureus.41976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2023] [Indexed: 08/19/2023] Open
Abstract
Background Scrub typhus is a reemerging, acute, undifferentiating febrile illness and one of the most neglected tropical diseases, calling for an in-depth investigation into its clinical diversity, complications, and mortality, which drives us to carry out this research work. Methods Over a year, prospective observational research was carried out after gaining parental consent and institutional ethical clearance, 206 children of either gender aged between one month and 12 years who had been hospitalized with a fever for at least five days and subsequently tested positive for Orientia tsutsugamushi were included in the study. Basic demographic information, clinical characteristics, laboratory findings, complications, related coinfections, and results were gathered and analyzed. A P-value of 0.05 was set as the statistical benchmark. Results The current study found that boys outnumbered girls. The ratio of boys to girls was 1.22:1, and the average age was 5.18 years. All had a fever (100%), and the other most frequently occurring clinical signs and symptoms were abdominal pain (16.99%), vomiting (22.33%), hepatosplenomegaly (49.51%), facial puffiness (39.32%), edema (27.18%), lymphadenopathy (19.90%), eschar (19.90%), macular-erythematous rash (17.96%), cough (21.84%), conjunctival congestion (25.24%), and headache (13.59%). Anemia (81.55%), leucocytosis (20.39%), leucopenia (6.8%), thrombocytopenia (49.51%), thrombocytosis (2.43%), and elevated serum levels of alanine aminotransferase (ALT, 57.28%) and aspartate aminotransferase (AST, 63.59%) were characteristic laboratory results. The coinfections were dengue, enteric fever, urinary tract infections, and malaria. Children who also had dengue were more likely to develop thrombocytopenia, which was statistically significant (P-value = 0.008). With doxycycline medication, early defervescence of fever occurred earlier than with azithromycin, and it was statistically significant (P-value = 0.000). The complications were hepatitis (63.59%), lower respiratory tract infections (LRTIs, 22.82%), scrub typhus meningoencephalitis (STME, 3.88%), acute kidney injury (AKI, 2.91%), myocarditis (1.46%), and acute disseminated encephalomyelitis (ADEM, 0.49%). Except for one who had ADEM, everyone was sent back home after receiving the best care possible. The average duration of hospital stay was 6.89 days. Conclusions Even in the absence of eschar, scrub typhus should be suspected in any febrile child who experiences clinical signs of meningoencephalitis syndrome, capillary leakage, skin rash, conjunctival congestion, LRTI, AKI, lymphadenopathy, hepatosplenomegaly, thrombocytopenia, and liver dysfunction in the post-monsoon season. Strong clinical suspicion and prompt anti-scrub drug administration go a long way in preventing or decreasing the morbidity and mortality of the same.
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Affiliation(s)
- Jadab Kumar Jana
- Pediatrics, Bankura Sammilani Medical College and Hospital, Bankura, IND
| | | | - Soumya Gayen
- Pediatrics, Bankura Sammilani Medical College and Hospital, Bankura, IND
| | - Dipti Mahata
- Pediatrics, Bankura Sammilani Medical College and Hospital, Bankura, IND
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Chung MH, Lee JS, Im JH. Antibiotic Combination Therapy for Severe Scrub Typhus: Is It Necessary? Infect Chemother 2023; 55:179-184. [PMID: 37407239 DOI: 10.3947/ic.2023.0055] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/16/2023] [Indexed: 07/07/2023] Open
Abstract
Scrub typhus can be adequately treated with doxycycline or azithromycin unless it is treated too late. Such cases present as severe scrub typhus, and their treatment remains a challenging problem. In this article, we briefly review the literature on the treatment of scrub typhus and the limitations of the combination of doxycycline and azithromycin. Several options are suggested for further study in the treatment of severe scrub typhus (such as encephalitis, myocarditis, and pneumonia), including dose escalation of doxycycline, the adjuvant use of steroids, the selective use of beta-lactam antibiotics, and the use of tigecycline.
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Affiliation(s)
| | - Jin-Soo Lee
- Division of Infectious Diseases, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Jae Hyoung Im
- Division of Infectious Diseases, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea.
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21
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Warrell CE, Osborne J, Mrcp LN, Gibney B, Carter DP, Warner J, Houlihan CF, Brooks TJG, Rampling T. Imported Rickettsial Infections to the United Kingdom, 2015-2020. J Infect 2023; 86:446-452. [PMID: 36948252 DOI: 10.1016/j.jinf.2023.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/13/2023] [Accepted: 03/15/2023] [Indexed: 03/24/2023]
Abstract
OBJECTIVE The burden of imported rickettsial infection in the UK is not previously described. This retrospective review identifies rickettsial cases diagnosed at the national reference laboratory between 2015-2022. METHODS Samples testing positive for spotted fever group, typhus group and scrub typhus IgG/IgM on acute and convalescent blood samples, and/or PCR on tissue/blood were categorised as suspected, confirmed or past infection. RESULTS 220 patients had rickettsioses, the commonest import was acute spotted fever group infection (61%, 125/205), 54% (62/114) from South Africa. Acute typhus group cases, 60% (40/67) from Southeast Asia. One patient with Rickettsia typhi bacteremia died. Scrub typhus group infections (5%, 10/205) were exclusively from Asia and the Western Pacific regions. Overall, 43% of confirmed cases (39/91) had not received doxycycline prior to results. CONCLUSIONS Rickettsial infections are important and under-recognised causes of imported fever in the UK. Thorough history, examination and timely treatment with doxycycline should be considered if there is suspicion of Rickettsia infection before testing.
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Affiliation(s)
- Clare E Warrell
- Rare and Imported Pathogens Laboratory, Salisbury, UK; London School of Hygiene and Tropical Medicine, London, UK.
| | - Jane Osborne
- Rare and Imported Pathogens Laboratory, Salisbury, UK
| | | | - Barry Gibney
- Rare and Imported Pathogens Laboratory, Salisbury, UK
| | | | | | - Catherine F Houlihan
- Rare and Imported Pathogens Laboratory, Salisbury, UK; Hospital for Tropical Diseaess, London, UCLH, UK; Department of Clinical Virology UCLH, UK; Infection and Immunity, University College London, United Kingdom
| | | | - Tommy Rampling
- Rare and Imported Pathogens Laboratory, Salisbury, UK; Hospital for Tropical Diseaess, London, UCLH, UK; Infection and Immunity, University College London, United Kingdom
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22
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Varghese GM, Dayanand D, Gunasekaran K, Kundu D, Wyawahare M, Sharma N, Chaudhry D, Mahajan SK, Saravu K, Aruldhas BW, Mathew BS, Nair RG, Newbigging N, Mathew A, Abhilash KPP, Biswal M, Prasad AH, Zachariah A, Iyadurai R, Hansdak SG, Sathyendra S, Sudarsanam TD, Prakash JAJ, Manesh A, Mohan A, Tarning J, Blacksell SD, Peerawaranun P, Waithira N, Mukaka M, Cheah PY, Peter JV, Abraham OC, Day NPJ. Intravenous Doxycycline, Azithromycin, or Both for Severe Scrub Typhus. N Engl J Med 2023; 388:792-803. [PMID: 36856615 PMCID: PMC7614458 DOI: 10.1056/nejmoa2208449] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND The appropriate antibiotic treatment for severe scrub typhus, a neglected but widespread reemerging zoonotic infection, is unclear. METHODS In this multicenter, double-blind, randomized, controlled trial, we compared the efficacy of intravenous doxycycline, azithromycin, or a combination of both in treating severe scrub typhus. Patients who were 15 years of age or older with severe scrub typhus with at least one organ involvement were enrolled. The patients were assigned to receive a 7-day course of intravenous doxycycline, azithromycin, or both (combination therapy). The primary outcome was a composite of death from any cause at day 28, persistent complications at day 7, and persistent fever at day 5. RESULTS Among 794 patients (median age, 48 years) who were included in the modified intention-to-treat analysis, complications included those that were respiratory (in 62%), hepatic (in 54%), cardiovascular (in 42%), renal (in 30%), and neurologic (in 20%). The use of combination therapy resulted in a lower incidence of the composite primary outcome than the use of doxycycline (33% and 47%, respectively), for a risk difference of -13.3 percentage points (95% confidence interval [CI], -21.6 to -5.1; P = 0.002). The incidence with combination therapy was also lower than that with azithromycin (48%), for a risk difference of -14.8 percentage points (95% CI, -23.1 to -6.5; P<0.001). No significant difference was seen between the azithromycin and doxycycline groups (risk difference, 1.5 percentage points; 95% CI, -7.0 to 10.0; P = 0.73). The results in the per-protocol analysis were similar to those in the primary analysis. Adverse events and 28-day mortality were similar in the three groups. CONCLUSIONS Combination therapy with intravenous doxycycline and azithromycin was a better therapeutic option for the treatment of severe scrub typhus than monotherapy with either drug alone. (Funded by the India Alliance and Wellcome Trust; INTREST Clinical Trials Registry-India number, CTRI/2018/08/015159.).
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Affiliation(s)
- George M Varghese
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Divya Dayanand
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Karthik Gunasekaran
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Debasree Kundu
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Mukta Wyawahare
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Navneet Sharma
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Dhruva Chaudhry
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Sanjay K Mahajan
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Kavitha Saravu
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Blessed W Aruldhas
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Binu S Mathew
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Roshini G Nair
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Nalini Newbigging
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Aswathy Mathew
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Kundavaram P P Abhilash
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Manisha Biswal
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Ann H Prasad
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Anand Zachariah
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Ramya Iyadurai
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Samuel G Hansdak
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Sowmya Sathyendra
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Thambu D Sudarsanam
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - John A J Prakash
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Abi Manesh
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Alladi Mohan
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Joel Tarning
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Stuart D Blacksell
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Pimnara Peerawaranun
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Naomi Waithira
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Mavuto Mukaka
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Phaik Yeong Cheah
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - John V Peter
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Ooriapadickal C Abraham
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
| | - Nicholas P J Day
- From the Departments of Infectious Diseases (G.M.V., D.D., D.K., R.G.N., A.H.P., A. Manesh), Medicine (K.G., N.N., A.Z., R.I., S.G.H., S.S., T.D.S., O.C.A.), Pharmacology (B.W.A., B.S.M., A. Mathew), Emergency Medicine (K.P.P.A.), Microbiology (J.A.J.P.), and Critical Care (J.V.P.), Christian Medical College, Vellore, the Department of Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry (M.W.), the Departments of Internal Medicine (N.S.) and Microbiology (M.B.), Post Graduate Institute of Medical Education and Research, Chandigarh, the Department of Pulmonary Care and Critical Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak (D.C.), the Department of Medicine, Indira Gandhi Medical College, Shimla (S.K.M.), the Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal (K.S.), and the Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati (A. Mohan) - all in India; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., S.D.B., P.P., N.W., M.M., P.Y.C., N.P.J.D.); and the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (J.T., S.D.B., N.W., M.M., P.Y.C., N.P.J.D.)
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23
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Song X, Xie S, Huang X, Chen Z. The diagnosis and treatment of scrub typhus should be emphasized in non-endemic areas: A retrospective case series study. Medicine (Baltimore) 2023; 102:e32988. [PMID: 36827009 DOI: 10.1097/md.0000000000032988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
The morbidity of tsutsugamushi is increasing and is no longer limited to endemic areas. Delayed diagnosis and inappropriate treatment can cause severe complications and increase mortality rates. We conducted a retrospective case series of patients with scrub typhus at our institution to report our experience and discuss the diagnostic modalities. We encountered 21 cases of scrub typhus at our institution between 2014 and 2022. The average age of the patients was 52 years (range: 22-63 years), 11 (52%) were farmers, and 11 (52%) had clear outdoor activities. Twenty (95%) patients had an ineffective history of general antibiotic treatment. The classic presentation was repeated fever in 95% of patients. Seventeen patients (81%) had eschar mainly on the groin (35%) and armpit (35%). Common laboratory findings included eosinophilia (95%), elevated alanine aminotransferase (95%), elevated aspartate aminotransferase (86%), thrombocytopenia (76%), lower hemoglobin (71%), and neutrophilia (38%). Six (29%) patients received the treatment of tigecycline, 4 (19%) patients received the treatment of doxycycline, and 11 (52%) patients received the treatment of minocycline. After 3 days of specific treatment, the eosinophilic levels showed a recovery trend. Twenty (95%) patients fully recovered, and 1 (5%) died. Careful physical examination and medical history are important for the early diagnosis of scrub typhus; clinicians in non-endemic areas need to strengthen their understanding of scrub typhus.
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Affiliation(s)
- Xin Song
- Medical Department of Nanchang University, Nanchang, Jiangxi, China
- Department of Emergency, Jiangxi Provincial People's Hospital, Nanchang, Jiangxi, China
| | - Shu Xie
- Department of Emergency, Jiangxi Provincial People's Hospital, Nanchang, Jiangxi, China
- The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Xinhui Huang
- Medical Department of Nanchang University, Nanchang, Jiangxi, China
- Department of Emergency, Jiangxi Provincial People's Hospital, Nanchang, Jiangxi, China
| | - Zhi Chen
- Department of Emergency, Jiangxi Provincial People's Hospital, Nanchang, Jiangxi, China
- The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
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24
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Walker DH, Mendell NL. A scrub typhus vaccine presents a challenging unmet need. NPJ Vaccines 2023; 8:11. [PMID: 36759505 PMCID: PMC9910236 DOI: 10.1038/s41541-023-00605-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 01/17/2023] [Indexed: 02/11/2023] Open
Abstract
Scrub typhus caused by the obligately intracellular bacterium, Orientia tsutsugamushi, is a major cause of life-threatening acute undifferentiated febrile illness in eastern Asia and the islands of the Western Pacific and Indian oceans. Since the estimation of an incidence of 1 million cases annually two decades ago, the number of cases has increased substantially in endemic regions, reappeared where the disease was forgotten, and spread northward. Trombiculid mites are both reservoir and vector. Despite 80 years of efforts to develop a vaccine, there is none. Protective immunity is mediated by antibodies and CD8 and CD4 T cells. Previous efforts have failed because of gaps in understanding immunity to O. tsutsugamushi, particularly the requirements for vaccine-induced immunity, lack of knowledge regarding immune memory in scrub typhus, and lack of attention to addressing the issue of cross-protection between strains. There are numerous strains of O. tsutsugamushi, and modestly durable immunity is strain-specific. Antibodies to the strain that caused infection are protective against challenges with the homologous strain but, despite reactivity with other immunodominant antigens, the immune serum does not protect against heterologous strains. Among the antigens detected by western immunoblot in immune sera (22-, 47-, 56-, 58-, and 110 kDa proteins), only the 56 kDa protein stimulates strong protection. This protein contains four hypervariable regions which are likely, on the basis of limited data, to be the targets of neutralizing antibodies. However, a method that definitively detects neutralizing antibody has yet to be developed. Only one study has used genomic data to pursue the discovery of protective antigens. Three conserved autotransporters were identified, and only immunization with ScaA provided protection against the homologous strain, but only 40% of animals were protected against challenge with a heterologous strain. A multiplex vaccine containing conformational antigens of the hypervariable regions of the 56 kDa protein of the strains of the greatest clinical and epidemiological importance, as well as conserved regions of the 56 kDa protein, ScaA, and other protective antigens identified by future genomic and bioinformatics methods should be developed and tested.
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Affiliation(s)
- David H. Walker
- grid.176731.50000 0001 1547 9964Department of Pathology, The University of Texas Medical Branch at Galveston, 301 University Blvd., Galveston, TX 77555 USA
| | - Nicole L. Mendell
- grid.176731.50000 0001 1547 9964Department of Pathology, The University of Texas Medical Branch at Galveston, 301 University Blvd., Galveston, TX 77555 USA
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25
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Acharya N, Acharya S, Shukla S, Potdar J, Waghe T, Kabra R. Acute Onset Postpartum Pleural Effusion: A Near-Miss Maternal Case Due to Scrub Typhus Infection. Cureus 2023; 15:e35142. [PMID: 36949983 PMCID: PMC10027019 DOI: 10.7759/cureus.35142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 02/18/2023] [Indexed: 02/20/2023] Open
Abstract
A 32-year-old puerperal patient developed acute onset breathlessness and fever on the third postoperative day. On evaluation, the patient was diagnosed to have scrub typhus pneumonia without any characteristic eschar. The condition was associated with pleural effusion, and it was drained. Azithromycin was used as the drug of choice due to the peripartum status of this patient. The patient improved due to early detection and multidisciplinary timely care. The safe outcome of this near-miss case suggests that fever profile workup, especially in scrub typhus endemic areas, should include scrub typhus testing even if classical signs are absent in the peripartum period.
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Affiliation(s)
- Neema Acharya
- Department of Obstetrics and Gynaecology, Datta Meghe Institute of Health and Education Research (DMIHER), Wardha, IND
| | - Sourya Acharya
- Department of Medicine, Datta Meghe Institute of Health and Education Research (DMIHER), Wardha, IND
| | - Samarth Shukla
- Department of Pathology, Datta Meghe Institute of Health and Education Research (DMIHER), Wardha, IND
| | - Jyotsana Potdar
- Department of Obstetrics and Gynaecology, Datta Meghe Institute of Health and Education Research (DMIHER), Wardha, IND
| | - Tejal Waghe
- Department of Obstetrics and Gynaecology, Datta Meghe Institute of Health and Education Research (DMIHER), Wardha, IND
| | - Ruchita Kabra
- Department of Medicine, Datta Meghe Institute of Health and Education Research (DMIHER), Wardha, IND
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26
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Liang Y, Wang H, Gonzales C, Thiriot J, Sunyakumthorn P, Melby PC, Sun J, Soong L. CCR7/dendritic cell axis mediates early bacterial dissemination in Orientia tsutsugamushi-infected mice. Front Immunol 2022; 13:1061031. [PMID: 36618364 PMCID: PMC9813216 DOI: 10.3389/fimmu.2022.1061031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022] Open
Abstract
Scrub typhus is a life-threatening zoonosis caused by the obligate intracellular bacterium Orientia tsutsugamushi (Ot) that is transmitted by the infected larvae of trombiculid mites. However, the mechanism by which Ot disseminates from the bite site to visceral organs remains unclear; host innate immunity against bacterial dissemination and replication during early infection is poorly understood. In this study, by using an intradermal infection mouse model and fluorescent probe-labeled Ot, we assessed the dynamic pattern of innate immune cell responses at the inoculation site. We found that neutrophils were the first responders to Ot infection and migrated into the skin for bacterial uptake. Ot infection greatly induced neutrophil activation, and Ot-neutrophil interaction remarkably promoted cell death both in vitro and in vivo. Depletion of neutrophils did not alter bacterial dissemination in mice, as evidenced by similar bacterial burdens in the skin and draining lymph nodes (dLN) at day 3, as well as in the lungs and brains at day 14, as compared to the control mice. Instead, dendritic cells (DCs) and macrophages played a role as a Trojan horse and transmitted Ot from the skin into dLN. Importantly, the absence of homing receptor CCR7 or neutralization of its ligand, CCL21, significantly impaired DC migration, resulting in reduced bacterial burdens in dLN. Taken together, our study sheds light on a CCR7/dendritic cell-mediated mechanism of early Ot dissemination and provides new insights into therapeutic and vaccine development strategies for scrub typhus.
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Affiliation(s)
- Yuejin Liang
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, United States,Institute for Human Infections and Immunity, University of Texas Medical Branch, Galveston, TX, United States,*Correspondence: Yuejin Liang, ; Lynn Soong,
| | - Hui Wang
- Institute for Human Infections and Immunity, University of Texas Medical Branch, Galveston, TX, United States,Department of Pathology, University of Texas Medical Branch, Galveston, TX, United States
| | - Casey Gonzales
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, United States
| | - Joseph Thiriot
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, United States
| | - Piyanate Sunyakumthorn
- Department of Veterinary Medicine, United States Army Medical Directorate, Armed Forces Research Institute of Medical Sciences (USAMD-AFRIMS), Bangkok, Thailand
| | - Peter C. Melby
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, United States,Institute for Human Infections and Immunity, University of Texas Medical Branch, Galveston, TX, United States,Department of Pathology, University of Texas Medical Branch, Galveston, TX, United States,Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States
| | - Jiaren Sun
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, United States,Institute for Human Infections and Immunity, University of Texas Medical Branch, Galveston, TX, United States,Department of Pathology, University of Texas Medical Branch, Galveston, TX, United States
| | - Lynn Soong
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, United States,Institute for Human Infections and Immunity, University of Texas Medical Branch, Galveston, TX, United States,Department of Pathology, University of Texas Medical Branch, Galveston, TX, United States,*Correspondence: Yuejin Liang, ; Lynn Soong,
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27
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Orientia tsutsugamushi OtDUB Is Expressed and Interacts with Adaptor Protein Complexes during Infection. Infect Immun 2022; 90:e0046922. [PMID: 36374099 PMCID: PMC9753657 DOI: 10.1128/iai.00469-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Orientia tsutsugamushi is an etiologic agent of scrub typhus, a globally emerging rickettsiosis that can be fatal. The bacterium's obligate intracellular lifestyle requires its interaction with host eukaryotic cellular pathways. The proteins it employs to do so and their functions during infection are understudied. Recombinant versions of the recently characterized O. tsutsugamushi deubiquitylase (OtDUB) exhibit high-affinity ubiquitin binding, mediate guanine nucleotide exchange to activate Rho GTPases, bind clathrin adaptor protein complexes 1 and 2, and bind the phospholipid phosphatidylserine. Whether OtDUB is expressed and its function during O. tsutsugamushi infection have yet to be explored. Here, OtDUB expression, location, and interactome during infection were examined. O. tsutsugamushi transcriptionally and translationally expresses OtDUB throughout infection of epithelial, monocytic, and endothelial cells. Results from structured illumination microscopy, surface trypsinization of intact bacteria, and acetic acid extraction of non-integral membrane proteins indicate that OtDUB peripherally associates with the O. tsutsugamushi cell wall and is at least partially present on the bacterial surface. Analyses of the proteins with which OtDUB associates during infection revealed several known O. tsutsugamushi cell wall proteins and others. It also forms an interactome with adapter protein complex 2 and other endosomal membrane traffic regulators. This study documents the first interactors of OtDUB during O. tsutsugamushi infection and establishes a strong link between OtDUB and the host endocytic pathway.
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Geography and prevalence of rickettsial infections in Northern Tamil Nadu, India: a cross-sectional study. Sci Rep 2022; 12:20798. [PMID: 36460687 PMCID: PMC9718799 DOI: 10.1038/s41598-022-21191-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/23/2022] [Indexed: 12/03/2022] Open
Abstract
Rickettsial infections and Q fever are a common cause of acute febrile illness globally. Data on the role of climate and altitude on the prevalence of these infections in lacking from Southern India. In this study, we determined the sero-prevalence of scrub typhus (ST), spotted fever (SF), murine typhus (MT) and Q Fever (QF) in 8 eight geographical regions of North Tamil Nadu by detecting IgG antibodies using ELISA. Totally we tested 2565 people from 86 localities. Among the 27.3% positives, approximately 5% were IgG positive for two or more infections. Sero-prevalence to rickettsioses and Q fever was highest for individuals from rural areas and increased with age (> 30 years). Those in the Nilgiris highlands (wetter and cooler) and Erode, which has the most land under irrigation, demonstrated the least exposure to rickettsioses and Q fever. Lowland plains (AOR: 8.4-22.9; 95% CI 3.1-55.3) and highland areas up to 1000 m (AOR: 6.1-10.3; 95% CI 2.4-23.9) showed the highest risk of exposure to scrub typhus. For spotted fever, the risk of exposure was highest in Jawadhi (AOR:10.8; 95% CI 2.6-44.3) and Kalrayan (AOR:16.6; 95% CI 4.1-66.2). Q fever positivity was most likely to be encountered in Salem (AOR: 5.60; 95% CI 1.01-31.08) and Kalrayan hills (AOR:12.3; 95% CI 2.9-51.6). Murine typhus risk was significant only in Tiruvannamalai (AOR:24.2; 95% CI 3.3-178.6). Our study suggests that prevalence of rickettsial infections and Q fever is low in areas which receive rainfall of ≥ 150 cm/year, with average minimum and maximum temperatures between 15 and 25 °C and elevation in excess of 2000 m. It is also less in well irrigated lowlands with dry climate. These preliminary findings need confirmation by active surveillance in these areas.
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29
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Wang Q, Sartorius B, Philip John Day N, James Maude R. Spatio-temporal occurrence, burden, risk factors and modelling methods for estimating scrub typhus burden from global to subnational resolutions: a systematic review protocol. Wellcome Open Res 2022. [DOI: 10.12688/wellcomeopenres.18533.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: Scrub typhus is a neglected life-threatening vector-borne disease mainly caused by the bacterium Orientia tsutsugamushi, which is occasionally transmitted to humans during feeding of larval mites. It has been estimated that more than 1 billion persons potentially threatened and 1 million clinical cases occur annually across the world; however, it is unclear how this estimate was computed (and what the original source was) and much remains unknown regarding its global burden and risk factors. This systematic review aims to provide a comprehensive overview of the spatial-temporal distribution of scrub typhus, associated burden and risk factors at global, national and subnational resolutions, and to review the burden estimation models used at those different scales. Methods: A systematic search for literature on scrub typhus occurrence, risk factors and modelling methods will be conducted. PubMed and five other databases will be searched for published literature, and Google Scholar and nine other databases will be used to search for grey literatures. All titles/abstracts of the searched records will be separately assessed by two reviewers, who will then screen the full-text of potential records to decide eligibility. Two reviewers will independently perform corresponding data extraction and finally cross-check using designed standardized forms. Data will be tabulated, synthesized descriptively, and summarized narratively for each review question. Where appropriate, meta-analyses will be conducted. The risk of bias will be assessed, and potential publication bias will be detected. Discussion: This review will provide a comprehensive understanding of the current occurrence, spatial-temporal distribution, and burden of scrub typhus, identify associated risk factors from global to subnational resolutions, consolidate the best practice modeling framework(s) to estimate the burden of scrub typhus at various geographic/temporal resolutions, and decompose the relative contributions of various risk factors at scale. PROSPERO Registration: CRD42022315209
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Alam AM, Gillespie CS, Goodall J, Damodar T, Turtle L, Vasanthapuram R, Solomon T, Michael BD. Neurological manifestations of scrub typhus infection: A systematic review and meta-analysis of clinical features and case fatality. PLoS Negl Trop Dis 2022; 16:e0010952. [PMID: 36441812 PMCID: PMC9731453 DOI: 10.1371/journal.pntd.0010952] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 12/08/2022] [Accepted: 11/07/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Scrub typhus has become a leading cause of central nervous system (CNS) infection in endemic regions. As a treatable condition, prompt recognition is vital. However, few studies have focused on describing the symptomology and outcomes of neurological scrub typhus infection. We conducted a systematic review and meta-analysis to report the clinical features and case fatality ratio (CFR) in patients with CNS scrub typhus infection. METHODS A search and analysis plan was published in PROSPERO [ID 328732]. A systematic search of PubMed and Scopus was performed and studies describing patients with CNS manifestations of proven scrub typhus infection were included. The outcomes studied were weighted pooled prevalence (WPP) of clinical features during illness and weighted CFR. RESULTS Nineteen studies with 1,221 (656 adults and 565 paediatric) patients were included. The most common clinical features in CNS scrub typhus were those consistent with non-specific acute encephalitis syndromes (AES), such as fever (WPP 100.0% [99.5%-100.0%, I2 = 47.8%]), altered sensorium (67.4% [54.9-78.8%, I2 = 93.3%]), headache (65.0% [51.5-77.6%, I2 = 95.1%]) and neck stiffness 56.6% (29.4-80.4%, I2 = 96.3%). Classical features of scrub typhus were infrequently identified; an eschar was found in only 20.8% (9.8%-34.3%, I2 = 95.4%) and lymphadenopathy in 24.1% (95% CI 11.8% - 38.9%, I2 = 87.8%). The pooled CFR (95% CI) was 3.6% (1.5%- 6.4%, I2 = 67.3%). Paediatric cohorts had a CFR of 6.1% (1.9-12.1%, I2 = 77%) whilst adult cohorts reported 2.6% (0.7-5.3%, I2 = 43%). CONCLUSION Our meta-analyses illustrate that 3.6% of patients with CNS manifestations of scrub typhus die. Clinicians should have a high index of suspicion for scrub typhus in patients presenting with AES in endemic regions and consider starting empiric treatment whilst awaiting results of investigations, even in the absence of classical signs such as an eschar or lymphadenopathy.
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Affiliation(s)
- Ali M. Alam
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, United Kingdom
- Barts Health NHS Trust, London, United Kingdom
| | - Conor S. Gillespie
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Jack Goodall
- Tropical & Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Tina Damodar
- Department of Neurovirology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Lance Turtle
- Tropical & Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- The Pandemic Institute, Liverpool, United Kingdom
- The NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, United Kingdom
| | - Ravi Vasanthapuram
- Department of Neurovirology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Tom Solomon
- The Pandemic Institute, Liverpool, United Kingdom
- The NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, United Kingdom
| | - Benedict D. Michael
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, United Kingdom
- The NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, United Kingdom
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
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Elliott I, Kumlert R, Thangnimitchok N, Blacksell SD, Tanganuchitcharnchai A, Paris DH, Newton PN, Morand S. Orientia tsutsugamushi in Chiggers and Small Mammals in Laos. Vector Borne Zoonotic Dis 2022; 22:505-511. [PMID: 36255415 PMCID: PMC7613890 DOI: 10.1089/vbz.2022.0029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Abstract
Background: Scrub typhus is a leading cause of febrile illness in Laos and accounts for a high burden of disease. There have been no previous studies on the causative agent, Orientia tsutsugamushi, in vector mites ("chiggers") or their small mammal hosts in Laos. Materials and Methods: Small mammals and free-living chiggers were trapped in districts of Vientiane Province and Capital. Tissues were tested for O. tsutsugamushi by PCR and serum for IgG to O. tsutsugamushi by immunofluorescence assays (IFAs). Chiggers removed from small mammals and collected in their free-living stage using black plates were identified and tested for O. tsutsugamushi by PCR. Results: Over an 18-month period, 131 small mammals of 14 species were collected in 5 districts. Seventy-eight of 131 small mammals were infested with chiggers, but all tissues were O. tsutsugamushi PCR negative. Eighteen species of chigger were identified and 1,609 were tested by PCR. A single pool of chiggers tested O. tsutsugamushi positive. Sera from 52 small mammals were tested by IFA, with 16 testing positive. Conclusions: These are the first molecular and serological data on O. tsutsugamushi in chiggers and small mammals in Laos. Further studies are needed to better understand the key vector species and ecology of scrub typhus in areas with high disease incidence in Laos.
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Affiliation(s)
- Ivo Elliott
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Rawadee Kumlert
- Division of Vector-Borne Diseases, Department of Disease Control, Ministry of Public Health, Nonthaburi, Thailand
| | - Neeranuch Thangnimitchok
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
| | - Stuart D. Blacksell
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ampai Tanganuchitcharnchai
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Daniel H. Paris
- Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Paul N. Newton
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Serge Morand
- MIVEGEC, CNRS, IRD, Montpellier University, Montpellier, France
- Faculty of Veterinary Technology, Kasetsart University, Bangkok, Thailand
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Muacevic A, Adler JR. Recent Threat of Scrub Typhus in India: A Narrative Review. Cureus 2022; 14:e30092. [PMID: 36381766 PMCID: PMC9641991 DOI: 10.7759/cureus.30092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 10/09/2022] [Indexed: 11/29/2022] Open
Abstract
Scrub typhus is an endemic illness transmitted by vectors and induced by bacteria. It is the most common and severe rickettsial disease. There are many more cases every year with a significant case fatality rate. Despite being a serious public health threat in India, it is uncertain how widespread and burdensome scrub typhus is. The scarcity of statistical information and pertinent health records on scrub typhus in the outbreak region demonstrates that there is still a significant knowledge gap about this neglected illness. Clinical manifestations of this illness include kidney failure, disability, and severe kidney failure. Undifferentiated symptoms, late diagnosis, and treatment failure are all responsible for deaths. Knowing about this disease is important from a public health point of view due to difficulties in specific diagnosis and a shortage of laboratory services in so many places. India is known to have scrub typhus cases, and doctors should be aware of this potentially dangerous but easily curable illness. The disease is highly difficult to identify clinically from other acute afebrile infections due to common symptoms and a paucity of the lesion in the Indian population. The mainstay of diagnosis is antibody-based serological testing. Within the first week of symptoms, scrub typhus can be diagnosed using molecular and serological tests. Our objective is to identify how severe scrub typhus is in India and to investigate the current epidemiology, etiology, complications, management, and treatment of the disease in both long-established endemic regions and new infection foci.
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Hwang JH, Kim J, Sun IO, Lee TH, Chung KM, Lee CS. New Genotypes and Diversity of Orientia tsutsugamushi DNA samples from Patients with Scrub Typhus in South Korea as Determined by Multilocus Sequence Typing. Am J Trop Med Hyg 2022; 107:420-426. [PMID: 35895396 PMCID: PMC9393445 DOI: 10.4269/ajtmh.21-0850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 03/19/2022] [Indexed: 08/03/2023] Open
Abstract
Orientia tsutsugamushi, an obligate intracellular organism, is the causative agent of scrub typhus. Multilocus sequence typing (MLST) is a genetic typing method that provides a unified bacterial isolate characterization approach. However, there are no comparative studies in South Korea on the genotypic properties of O. tsutsugamushi based on MLST. To conduct a comparative analysis with previous data collected from Thailand, Laos, and Japan, we investigated the genetic diversity of O. tsutsugamushi from 51 patients with scrub typhus in South Korea by using MLST. The MLST analysis revealed 10 new alleles in the housekeeping genes: gpsA, n = 2; mdh, n = 1; nrdB, n = 1; nuoF, n = 1; ppdK, n = 1; sucB, n = 2; and sucD, n = 2. These novel alleles led to the assignment of six new sequence types (STs) (ST93-98). The 51 samples corresponded to seven different STs (ST48 and ST93-98), with ST48 accounting for the largest proportion (49.0%) of O. tsutsugamushi STs in South Korea. Interestingly, O. tsutsugamushi from patients with scrub typhus in South Korea were clustered in two different clades, and the five Korean STs (ST48, ST93, ST94, ST95, and ST98) were close genetically to ST80, which was isolated from Laos. The remaining two STs (ST96 and ST97) were close genetically to ST49 (Ikeda, Japan). Overall, our results suggest that the relative genetic stability and the clonal populations of O. tsutsugamushi strains in South Korea have remained mostly conserved.
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Affiliation(s)
- Joo-Hee Hwang
- Department of Internal Medicine, Jeonbuk National University Medical School, Jeonju, Republic of Korea
- Research Institute of Clinical Medicine of Jeonbuk National University–Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea
| | - Jeongsik Kim
- Faculty of Science Education, Jeju National University, Jeju, Republic of Korea
- Interdisciplinary Graduate Program in Advanced Convergence Technology & Science, Jeju National University, Jeju, Republic of Korea
| | - In O. Sun
- Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Republic of Korea
| | - Tae Hee Lee
- Department of Microbiology and Immunology, Jeonbuk National University Medical School, Jeonju, Republic of Korea
- Institute for Medical Science, Jeonbuk National University Medical School, Jeonju, Republic of Korea
| | - Kyung Min Chung
- Research Institute of Clinical Medicine of Jeonbuk National University–Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea
- Department of Microbiology and Immunology, Jeonbuk National University Medical School, Jeonju, Republic of Korea
- Institute for Medical Science, Jeonbuk National University Medical School, Jeonju, Republic of Korea
| | - Chang-Seop Lee
- Department of Internal Medicine, Jeonbuk National University Medical School, Jeonju, Republic of Korea
- Research Institute of Clinical Medicine of Jeonbuk National University–Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea
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Kumar P, Prasad A, Kumar S, Akhtar A. Scrub Typhus Presenting as Acute Flaccid Paralysis in a Child: A Differential to Be Included in a Common Presentation. Cureus 2022; 14:e27909. [PMID: 36120204 PMCID: PMC9467491 DOI: 10.7759/cureus.27909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2022] [Indexed: 11/12/2022] Open
Abstract
Neurological manifestations are common in scrub typhus in children. A 12-year-old girl presented with acute onset fever, bilateral lower limb weakness, and urinary retention. On initial investigations, scrub typhus immunoglobulin M (IgM) ELISA (enzyme-linked immunosorbent assay) was reactive. She was given an injection of doxycycline along with other supportive therapies. Her symptoms improved gradually and bilateral lower limb power came back gradually without residual weakness by the 13th day of admission.
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Inthawong M, Sunyakumthorn P, Wongwairot S, Anantatat T, Dunachie SJ, Im-Erbsin R, Jones JW, Mason CJ, Lugo LA, Blacksell SD, Day NPJ, Sonthayanon P, Richards AL, Paris DH. A time-course comparative clinical and immune response evaluation study between the human pathogenic Orientia tsutsugamushi strains: Karp and Gilliam in a rhesus macaque (Macaca mulatta) model. PLoS Negl Trop Dis 2022; 16:e0010611. [PMID: 35925895 PMCID: PMC9352090 DOI: 10.1371/journal.pntd.0010611] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 06/27/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Scrub typhus is a vector-borne febrile illness caused by Orientia tsutsugamushi transmitted by the bite of Trombiculid mites. O. tsutsugamushi has a high genetic diversity and is increasingly recognized to have a wider global distribution than previously assumed. METHODOLOGY/PRINCIPLE FINDINGS We evaluated the clinical outcomes and host immune responses of the two most relevant human pathogenic strains of O. tsutsugamushi; Karp (n = 4) and Gilliam (n = 4) in a time-course study over 80 days post infection (dpi) in a standardized scrub typhus non-human primate rhesus macaque model. We observed distinct features in clinical progression and immune response between the two strains; Gilliam-infected macaques developed more pronounced systemic infection characterized by an earlier onset of bacteremia, lymph node enlargement, eschar lesions and higher inflammatory markers during the acute phase of infection, when compared to the Karp strain. C-reactive protein (CRP) plasma levels, interferon gamma (IFN-γ, interleukin-1 receptor antagonist (IL-1ra), IL-15 serum concentrations, CRP/IL10- and IFN-γ/IL-10 ratios correlated positively with bacterial load in blood, implying activation of the innate immune response and preferential development of a T helper-type 1 immune response. The O. tsutsugamushi-specific immune memory responses in cells isolated from skin and lymph nodes at 80 dpi were more markedly elevated in the Gilliam-infected macaques than in the Karp-infected group. The comparative cytokine response dynamics of both strains revealed significant up-regulation of IFN-γ, tumor necrosis factor (TNF), IL-15, IL-6, IL-18, regulatory IL-1ra, IL-10, IL-8 and granulocyte-colony-stimulating factor (G-CSF). These data suggest that the clinical outcomes and host immune responses to scrub typhus could be associated with counter balancing effects of pro- and anti-inflammatory cytokine-mediated responses. Currently, no data on characterized time-course comparisons of O. tsutsugamushi strains regarding measures of disease severity and immune response is available. Our study provides evidence for the strain-specificity of host responses in scrub typhus, which supports our understanding of processes at the initial inoculation site (eschar), systemic disease progression, protective and/or pathogenic host immune mechanisms and cellular immune memory function. CONCLUSIONS/SIGNIFICANCE This study characterised an improved intradermal rhesus macaque challenge model for scrub typhus, whereby the Gilliam strain infection associated with higher disease severity in the rhesus macaque model than the previous Karp strain infection. Difficulties associated with inoculum quantitation for obligate-intracellular bacteria were overcome by using functional inoculum titrations in outbred mice. The Gilliam-based rhesus macaque model provides improved endpoint measurements and contributes towards the identification of correlates of protection for future vaccine development.
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Affiliation(s)
- Manutsanun Inthawong
- Department of Veterinary Medicine, United States Army Medical Directorate, Armed Forces Research Institute of Medical Sciences (USAMD-AFRIMS), Bangkok, Thailand
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Piyanate Sunyakumthorn
- Department of Veterinary Medicine, United States Army Medical Directorate, Armed Forces Research Institute of Medical Sciences (USAMD-AFRIMS), Bangkok, Thailand
| | - Sirima Wongwairot
- Department of Veterinary Medicine, United States Army Medical Directorate, Armed Forces Research Institute of Medical Sciences (USAMD-AFRIMS), Bangkok, Thailand
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Tippawan Anantatat
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Diagnostic Medicine/Pathobiology, College of Veterinary Medicine, Kansas State University, Manhattan, Kansas, United States of America
| | - Susanna J. Dunachie
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
| | - Rawiwan Im-Erbsin
- Department of Veterinary Medicine, United States Army Medical Directorate, Armed Forces Research Institute of Medical Sciences (USAMD-AFRIMS), Bangkok, Thailand
| | - James W. Jones
- Department of Veterinary Medicine, United States Army Medical Directorate, Armed Forces Research Institute of Medical Sciences (USAMD-AFRIMS), Bangkok, Thailand
| | - Carl J. Mason
- Department of Veterinary Medicine, United States Army Medical Directorate, Armed Forces Research Institute of Medical Sciences (USAMD-AFRIMS), Bangkok, Thailand
| | - Luis A. Lugo
- Department of Veterinary Medicine, United States Army Medical Directorate, Armed Forces Research Institute of Medical Sciences (USAMD-AFRIMS), Bangkok, Thailand
| | - Stuart D. Blacksell
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
| | - Nicholas P. J. Day
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
| | - Piengchan Sonthayanon
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Allen L. Richards
- Viral & Rickettsial Diseases Department, Naval Medical Research Center, Silver Spring, Maryland, United States of America
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
| | - Daniel H. Paris
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
- Department of Medicine, Swiss Tropical and Public Health Institute, Faculty of Medicine, University of Basel, Switzerland
- Department of Clinical Research, Faculty of Medicine, University of Basel, Switzerland
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Ghosh R, Mandal A, León-Ruiz M, Roy D, Das S, Dubey S, Benito-León J. Rare neurological and neuropsychiatric manifestations of scrub typhus: a case series of 10 cases. Neurologia 2022:S2173-5808(22)00081-5. [PMID: 35907627 DOI: 10.1016/j.nrleng.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 06/09/2022] [Indexed: 10/16/2022] Open
Abstract
INTRODUCTION Scrub typhus is a potentially life-threatening but curable disease that can produce multi-organ failure. Neurological manifestations in scrub typhus have gained attention recently, where the entire neural axis except the myoneural junction can be involved. Although the pathogenesis of neurological involvement has not been established, immune-mediated mechanisms are suspected. This article reports the clinicopathological features of scrub typhus cases presenting several rare neurological and neuropsychiatric manifestations. METHODS Three hundred fifty-four serologically confirmed scrub typhus cases were admitted to the Department of General Medicine of Burdwan Medical College and Hospital (West Bengal, India) between May 2018 and May 2022. There were 50 patients who had predominantly neurological manifestations. Of these 50 cases, ten patients presented with extremely rare neurological manifestations. RESULTS We report 10 cases of scrub typhus (four men and six women) who presented with complex neurological pictures (posterior reversible encephalopathy syndrome, Opalski syndrome, parkinsonism, cerebellitis, isolated opsoclonus, acute transverse myelitis, myositis, polyradiculoneuropathy with cranial neuropathy, acute transient behavioral changes, and fibromyalgia). Immune-mediated mechanisms might have mediated the pathogenesis of most cases following scrub typhus infection. CONCLUSION From a clinicopathological point of view, each case was unique in its presentation and treatment response. In any acute onset neurological disorders associated with febrile illness in the tropics or subtropics, scrub typhus infection should be included in the differential diagnosis, despite the absence of eschar and unremarkable neuroimaging findings. This otherwise curable disease may result in multi-organ dysfunction syndrome and death if the diagnosis is delayed.
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Affiliation(s)
- Ritwik Ghosh
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Arpan Mandal
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Moisés León-Ruiz
- Section of Clinical Neurophysiology, Department of Neurology, University Hospital "La Paz", Madrid, Spain
| | - Dipayan Roy
- Indian Institute of Technology (IIT), Madras, Tamil Nadu, India; School of Humanities, Indira Gandhi National Open University, New Delhi, India
| | - Shambaditya Das
- Department of Neuromedicine, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research & SSKM Hospital, Kolkata, West Bengal, India
| | - Souvik Dubey
- Department of Neuromedicine, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research & SSKM Hospital, Kolkata, West Bengal, India
| | - Julián Benito-León
- Department of Neurology, University Hospital "12 de Octubre", Madrid, Spain; Centro de Investigación Biomédica en Red Sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain; Department of Medicine, Complutense University, Madrid, Spain.
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Unni S, Eswaradass SKC, Krishnan Nair H, Anandan S, Mani I, Eswaradass PV. Scrub Typhus Meningoencephalitis: Review of Literature and Unique Diagnostic & Management Challenges in Resource-Limited Settings. Cureus 2022; 14:e26369. [PMID: 35911355 PMCID: PMC9329600 DOI: 10.7759/cureus.26369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2022] [Indexed: 11/05/2022] Open
Abstract
Scrub typhus is a zoonotic febrile illness caused by Orientia tsutsugamushi and transmitted by Leptotrombidium larvae. Scrub typhus often presents with nonspecific clinical features, and ranges in severity from mild illness to multiorgan failure and fatality. The disease is primarily found in the Asia-Pacific rim, including India, Pakistan, Thailand, Malaysia, Korea, and China. Due to frequent limitations in healthcare resources in many of these countries, the diagnosis and management of scrub typhus meningoencephalitis pose unique challenges. This review focuses on the epidemiology, clinical features, diagnostic testing, and management modalities in such resource-limited settings. Exercising a high index of clinical suspicion and timely diagnostic tests and management strategies are vital to prevent life-threatening complications of this treatable illness.
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Atwal S, Wongsantichon J, Giengkam S, Saharat K, Pittayasathornthun YJ, Chuenklin S, Wang LC, Chung T, Huh H, Lee SH, Sobota RM, Salje J. The obligate intracellular bacterium Orientia tsutsugamushi differentiates into a developmentally distinct extracellular state. Nat Commun 2022; 13:3603. [PMID: 35739103 PMCID: PMC9226355 DOI: 10.1038/s41467-022-31176-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 06/03/2022] [Indexed: 11/13/2022] Open
Abstract
Orientia tsutsugamushi (Ot) is an obligate intracellular bacterium in the family Rickettsiaceae that causes scrub typhus, a severe mite-borne human disease. Its mechanism of cell exit is unusual amongst Rickettsiaceae, as Ot buds off the surface of infected cells enveloped in plasma membrane. Here, we show that Ot bacteria that have budded out of host cells are in a distinct developmental stage compared with intracellular bacteria. We refer to these two stages as intracellular and extracellular bacteria (IB and EB, respectively). These two forms differ in physical properties: IB is both round and elongated, and EB is round. Additionally, IB has higher levels of peptidoglycan and is physically robust compared with EB. The two bacterial forms differentially express proteins involved in bacterial physiology and host-pathogen interactions, specifically those involved in bacterial dormancy and stress response, and outer membrane autotransporter proteins ScaA and ScaC. Whilst both populations are infectious, entry of IB Ot is sensitive to inhibitors of both clathrin-mediated endocytosis and macropinocytosis, whereas entry of EB Ot is only sensitive to a macropinocytosis inhibitor. Our identification and detailed characterization of two developmental forms of Ot significantly advances our understanding of the intracellular lifecycle of an important human pathogen. Orientia tsutsugamushi (Ot) the causing agent of scrub typhus exits infected cells using a unique mechanism that involves budding off the surface of infected cells. Here, Atwal et al. report that Ots that have budded from their host cells are in a distinct developmental stage than intracellular bacteria and provide the first characterization of this extracellular stage. Both forms are infectious but differ in their physical properties, proteome, and entry mechanism into host cells.
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Affiliation(s)
- Sharanjeet Atwal
- Public Health Research Institute, Rutgers the State University of New Jersey, Newark, NJ, USA
| | - Jantana Wongsantichon
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Suparat Giengkam
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kittirat Saharat
- Public Health Research Institute, Rutgers the State University of New Jersey, Newark, NJ, USA
| | | | - Suthida Chuenklin
- Public Health Research Institute, Rutgers the State University of New Jersey, Newark, NJ, USA.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Loo Chien Wang
- Functional Proteomics Laboratory, Institute of Molecular and Cell Biology, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore.,SingMass-National Mass Spectrometry Laboratory, Institute of Molecular and Cell Biology, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - Taerin Chung
- Institute for Quantitative Biomedicine, Rutgers University, Piscataway, NJ, USA
| | - Hyun Huh
- Institute for Quantitative Biomedicine, Rutgers University, Piscataway, NJ, USA
| | - Sang-Hyuk Lee
- Institute for Quantitative Biomedicine, Rutgers University, Piscataway, NJ, USA.,Department of Physics and Astronomy, Rutgers University, Piscataway, NJ, USA
| | - Radoslaw M Sobota
- Functional Proteomics Laboratory, Institute of Molecular and Cell Biology, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore.,SingMass-National Mass Spectrometry Laboratory, Institute of Molecular and Cell Biology, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - Jeanne Salje
- Public Health Research Institute, Rutgers the State University of New Jersey, Newark, NJ, USA. .,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
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Kumar M, Valiaveetil KA, Chandran J, Mohan VR, Chandrasekar K, Ghosh U, Punnen A, Rose W. Scrub Typhus: A Spatial and Temporal Analysis from South India. J Trop Pediatr 2022; 68:6651465. [PMID: 35903921 DOI: 10.1093/tropej/fmac054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Scrub typhus is a zoonotic rickettsial disease caused by the bacterium Orientia tsutsugamushi. The non-specificity of presentation, low index of suspicion and the poor availability of diagnostic tests often lead to delayed diagnosis and significant morbidity and mortality. Temperature, humidity, rainfall and Normalized Difference Vegetation Index (NDVI) on the spatio-temporal clustering of scrub typhus cases in children in three contiguous administrative districts in South India over 5 years were studied. A total of 419 children were diagnosed with scrub typhus during the study period. A surge of children with scrub typhus was noted when the NVDI ranged between 0.6 and 0.8 µm. Temperature, humidity and rainfall had a major role in the incidence of scrub typhus.
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Affiliation(s)
- Madhan Kumar
- Department of Paediatrics, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Jolly Chandran
- Department of Paediatrics, Christian Medical College, Vellore, Tamil Nadu, India
| | - Venkata Raghava Mohan
- Department of Community Health, Christian Medical College, Vellore, Tamil Nadu, India
| | - K Chandrasekar
- Crop Parameter Retrieval Division, Agricultural Sciences Applications Group, National Remote Sensing Centre, Hyderabad, India
| | - Urmi Ghosh
- Department of Paediatrics, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anu Punnen
- Department of Paediatrics, Christian Medical College, Vellore, Tamil Nadu, India
| | - Winsley Rose
- Department of Paediatrics, Christian Medical College, Vellore, Tamil Nadu, India
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Lallawmkima I, Vanlalruati RSC, Chongthu JL, Renthlei L. Scrub Typhus with Multi-Organ Dysfunction Syndrome and Immune Thrombocytopenia: A Case Report. INFECTIOUS DISEASES & CLINICAL MICROBIOLOGY 2022; 4:133-136. [PMID: 38633345 PMCID: PMC10986586 DOI: 10.36519/idcm.2022.95] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 03/06/2022] [Indexed: 04/19/2024]
Abstract
Scrub typhus is a mite-borne infectious disease caused by Orientia tsutsugamushi, a gram-negative intracellular bacterium. It is a severe public health problem that affects mainly Asia-Pacific areas. Scrub typhus threatens one billion people and causes illness worldwide each year. Approximately one-third of the cases may suffer from multiple organ dysfunction syndrome (MODS) during the disease course. Thrombocytopenia is another critical clinical manifestation of scrub typhus, and thrombocytopenia is one of the causes of MODS. Scrub typhus is rare and hard to diagnose and treat. Given the close similarity in the clinical presentation of several tropical illnesses, a meticulous history and detailed physical examination need to be emphasized. In this study, we reported a case of scrub typhus with thrombocytopenia and MODS, which is only the third case worldwide.
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Affiliation(s)
| | - RSC Vanlalruati
- Department of Microbiology, Civil Hospital Lunglei, Mizoram, India
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Systematic Surveillance of Rickettsial Diseases in 27 Hospitals from 26 Provinces throughout Vietnam. Trop Med Infect Dis 2022; 7:tropicalmed7060088. [PMID: 35736967 PMCID: PMC9231031 DOI: 10.3390/tropicalmed7060088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 05/28/2022] [Accepted: 05/29/2022] [Indexed: 11/27/2022] Open
Abstract
In Vietnam, the public health burden of rickettsial infections continues to be underestimated due to knowledge gaps in the epidemiology of these diseases. We conducted a systematic study among 27 hospitals from 26 provinces in eight ecological regions throughout Vietnam to investigate the prevalence, distribution, and clinical characteristics of rickettsial diseases. We recruited 1834 patients in the study from April 2018 to October 2019. The findings showed that rickettsial diseases were common among undifferentiated febrile patients, with 564 (30.8%) patients positive by qPCR for scrub typhus, murine typhus or spotted fever. Scrub typhus (484, 85.8%) was the most common rickettsial disease, followed by murine typhus (67, 11.9%) and spotted fever (10, 1.8%). Rickettsial diseases were widely distributed in all regions of Vietnam and presented with nonspecific clinical manifestations.
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Tran HTD, Schindler C, Pham TTT, Vien MQ, Do HM, Ngo QT, Nguyen TB, Hoang HTH, Vu LTH, Schelling E, Paris DH. Simple clinical and laboratory predictors to improve empirical treatment strategies in areas of high scrub typhus and dengue endemicity, central Vietnam. PLoS Negl Trop Dis 2022; 16:e0010281. [PMID: 35507541 PMCID: PMC9067661 DOI: 10.1371/journal.pntd.0010281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 02/24/2022] [Indexed: 11/30/2022] Open
Abstract
Background Dengue fever is highly endemic in Vietnam, but scrub typhus—although recognized as an endemic disease—remains underappreciated. These diseases together are likely to account for more than half of the acute undifferentiated fever burden in Vietnam. Scrub typhus (ST) is a bacterial disease requiring antimicrobial treatment, while dengue fever (DF) is of viral etiology and does not. The access to adequate diagnostics and the current understanding of empirical treatment strategies for both illnesses remain limited. In this study we aimed to contribute to the clinical decision process in the management of these two important etiologies of febrile illness in Vietnam. Methods Using retrospective data from 221 PCR-confirmed scrub typhus cases and 387 NS1 protein positive dengue fever patients admitted to five hospitals in Khanh Hoa province (central Vietnam), we defined predictive characteristics for both diseases that support simple clinical decision making with potential to inform decision algorithms in future. We developed models to discriminate scrub typhus from dengue fever using multivariable logistic regression (M-LR) and classification and regression trees (CART). Regression trees were developed for the entire data set initially and pruned, based on cross-validation. Regression models were developed in a training data set involving 60% of the total sample and validated in the complementary subsample. Probability cut points for the distinction between scrub typhus and dengue fever were chosen to maximise the sum of sensitivity and specificity. Results Using M-LR, following seven predictors were identified, that reliably differentiate ST from DF; eschar, regional lymphadenopathy, an occupation in nature, increased days of fever on admission, increased neutrophil count, decreased ratio of neutrophils/lymphocytes, and age over 40. Sensitivity and specificity of predictions based on these seven factors reached 93.7% and 99.5%, respectively. When excluding the “eschar” variable, the values dropped to 76.3% and 92.3%, respectively. The CART model generated one further variable; increased days of fever on admission, when eschar was included, the sensitivity and specificity was 95% and 96.9%, respectively. The model without eschar involved the following six variables; regional lymphadenopathy, increased days of fever on admission, increased neutrophil count, increased lymphocyte count, platelet count ≥ 47 G/L and age over 28 years as predictors of ST and provided a sensitivity of 77.4% and a specificity of 90.7%. Conclusions The generated algorithms contribute to differentiating scrub typhus from dengue fever using basic clinical and laboratory parameters, supporting clinical decision making in areas where dengue and scrub typhus are co-endemic in Vietnam. Dengue fever is highly endemic in Vietnam, while scrub typhus is recognized as a re-emerging neglected disease. Both diseases are likely to account for more than half of the acute undifferentiated fever burden in Vietnam. However, scrub typhus is a bacterial disease requiring antimicrobial treatment, while dengue fever—of viral etiology—does not. Misdiagnosis and treatment delays cause potentially severe or fatal complications among scrub typhus patients, even though it is easily treatable. In this study, we used simple clinical and laboratory markers, which were identified upon admission of 221 PCR-confirmed scrub typhus cases and 387 NS1-positive dengue fever patients from Khanh Hoa province to identify the differences between scrub typhus and dengue. We found seven predictors that served to construct a simple clinical decision tree, holding great potential to distinguish scrub typhus from dengue using readily available clinical or laboratory findings. These predictors can strongly support medical staff in identifying scrub typhus cases from dengue, without using sophisticated diagnostic tests, and could improve the quality of diagnoses and appropriate treatment strategies at the primary health care level–especially in areas where scrub typhus and dengue fever are co-endemic in Vietnam and many parts of Asia and where diagnostic tests are not readily available.
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Affiliation(s)
- Hanh Thi Duc Tran
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
- Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland
- Department of Epidemiology, Hanoi University of Public Health, Hanoi, Vietnam
- University of Basel, Basel, Switzerland
| | - Christian Schindler
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Thuy Thi Thanh Pham
- Department of Infectious Diseases, Bach Mai Hospital, Hanoi, Vietnam
- The Partnership for Health Advancement in Vietnam (HAIVN), Hanoi, Vietnam
| | | | - Hung Manh Do
- Department for Infectious Disease Control and Prevention, Nha Trang Pasteur Institute, Khanh Hoa, Vietnam
| | - Quyet Thi Ngo
- Department of Microbiology and Immunology, Nha Trang Pasteur Institute, Khanh Hoa, Vietnam
| | - Trieu Bao Nguyen
- Department of Microbiology and Immunology, Nha Trang Pasteur Institute, Khanh Hoa, Vietnam
| | - Hang Thi Hai Hoang
- Department for Infectious Disease Control and Prevention, Nha Trang Pasteur Institute, Khanh Hoa, Vietnam
| | - Lan Thi Hoang Vu
- Department of Epidemiology, Hanoi University of Public Health, Hanoi, Vietnam
| | | | - Daniel H. Paris
- Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- * E-mail:
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Guan XG, Wei YH, Jiang BG, Zhou SX, Zhang AR, Lu QB, Zhou ZW, Chen JJ, Zhang HY, Ji Y, Yang Y, Fang LQ, Li H, Yang ZC, Liu W. Clinical characteristics and risk factors for severe scrub typhus in pediatric and elderly patients. PLoS Negl Trop Dis 2022; 16:e0010357. [PMID: 35486642 PMCID: PMC9053809 DOI: 10.1371/journal.pntd.0010357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/25/2022] [Indexed: 11/30/2022] Open
Abstract
Background Scrub typhus (ST) is a life-threatening infectious disease if appropriate treatment is unavailable. Large discrepancy of clinical severity of ST patients was reported among age groups, and the underlying risk factors for severe disease are unclear. Methods Clinical and epidemiological data of ST patients were collected in 55 surveillance hospitals located in Guangzhou City, China, from 2012 to 2018. Severe prognosis and related factors were determined and compared between pediatric and elderly patients. Results A total of 2,074 ST patients including 209 pediatric patients and 1,865 elderly patients were included, with a comparable disease severity rate of 11.0% (95% CI 7.1%–16.1%) and 10.3% (95% CI 9.0%–11.8%). Different frequencies of clinical characteristics including lymphadenopathy, skin rash, enlarged tonsils, etc. were observed between pediatric and elderly patients. Presence of peripheral edema and decreased hemoglobin were the most important predictors of severe illness in pediatric patients with adjusted ORs by 38.99 (9.96–152.67, p<0.001) and 13.22 (1.54–113.50, p = 0.019), respectively, while presence of dyspnea and increased total bilirubin were the potential determinants of severe disease in elderly patients with adjusted ORs by 11.69 (7.33–18.64, p<0.001) and 3.17 (1.97–5.11, p<0.001), respectively. Compared with pediatric patients, elderly patients were more likely to receive doxycycline (64.8% v.s 9.9%, p<0.001), while less likely to receive azithromycin therapy (5.0% v.s 41.1%, p<0.001). Conclusion The disease severity rate is comparable between pediatric and elderly ST patients, while different clinical features and laboratory indicators were associated with development of severe complications for pediatric and elderly patients, which is helpful for diagnosis and progress assessment of disease for ST patients. The study investigated different clinical features and risk factors for severe disease between pediatric and elderly patients with scrub typhus. We found that significantly higher frequencies of lymphadenopathy, skin rash, enlarged tonsils, etc. were observed in pediatric patients than elderly patients. Other non-specific signs, subjective complaints, and chest radiographic abnormality were overpresented in elderly patients. Risk factors for severe disease between pediatric and elderly patients with scrub typhus were different. Presence of peripheral edema and decreased hemoglobin were the most important factors for pediatric patients, while presence of dyspnea and increased total bilirubin for elderly patients. These findings reminded medical workers to acknowledge this important difference and to adopt an age specific method in the differential diagnosis and risk assessment for scrub typhus.
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Affiliation(s)
- Xiu-Gang Guan
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Yue-Hong Wei
- Guangzhou Center for Disease Control and Prevention, Guangzhou, China
| | - Bao-Gui Jiang
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Shi-Xia Zhou
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
- School of Public Health, Anhui Medical University, Hefei, China
| | - An-Ran Zhang
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
- School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Qing-Bin Lu
- Department of Laboratorial Science and Technology, School of Public Health, Peking University, Beijing, China
| | - Zi-Wei Zhou
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Jin-Jin Chen
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Hai-Yang Zhang
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Yang Ji
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Yang Yang
- Department of Biostatistics, College of Public Health and Health Professions, and Emerging Pathogens Institute, University of Florida, Gainesville, Florida, United States of America
| | - Li-Qun Fang
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
- School of Public Health, Anhui Medical University, Hefei, China
- * E-mail: (LQF); (HL); (ZCY); (WL)
| | - Hao Li
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
- * E-mail: (LQF); (HL); (ZCY); (WL)
| | - Zhi-Cong Yang
- Guangzhou Center for Disease Control and Prevention, Guangzhou, China
- * E-mail: (LQF); (HL); (ZCY); (WL)
| | - Wei Liu
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
- Department of Laboratorial Science and Technology, School of Public Health, Peking University, Beijing, China
- * E-mail: (LQF); (HL); (ZCY); (WL)
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Hong K, Shu Z, Li L, Zhong Y, Chen W, Nong C, Kong J. Diagnostic Value of CD4/CD8 in Scrub Typhus. Am J Trop Med Hyg 2022; 106:792-797. [PMID: 34902835 PMCID: PMC8922489 DOI: 10.4269/ajtmh.21-0531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 10/20/2021] [Indexed: 11/07/2022] Open
Abstract
Scrub typhus is often misdiagnosed in febrile patients, leading to antibiotic abuse and multiple complications. We conducted a retrospective record review at the Fourth Affiliated Hospital of Guangxi Medical University in China. Data were collected on 52 patients with a confirmed diagnosis of scrub typhus and complete clinical data. In addition, data were collected on 52 patients with bloodstream infection, 25 patients with HIV infection, 112 patients with common community-acquired pneumonia (CCAP), and 36 patients with severe community-acquired pneumonia (SCAP) to serve as control groups. The peripheral blood CD4 and CD8 counts, CD4/CD8 ratio, C-reactive protein, procalcitonin, alanine aminotransferase, aspartate aminotransferase, creatinine, and β2 microglobulin levels; and the white blood cell count and neutrophil percentage were compared between the scrub typhus and the control groups. The value of these biomarkers in the diagnosis of scrub typhus was assessed using receiver-operating characteristic curve analysis. The scrub typhus group had a significantly lower CD4 count and CD4/CD8 ratio than the bloodstream infection, CCAP, and SCAP groups, and a significantly greater CD4 count and CD4/CD8 ratio than the HIV infection group. In contrast, the scrub typhus group had a significantly greater CD8 count than the bloodstream infection and CCAP and SCAP groups, and it had a lower level of CD8 than the HIV infection group. The areas under the curve of CD4/CD8 were more than 0.93 in the receiver-operating characteristic curve analysis. These findings suggest that the CD4/CD8 ratio is a useful ancillary test for diagnosing scrub typhus.
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Affiliation(s)
- Kangkang Hong
- Pulmonary and Critical Care Medicine Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China;,Department of Geriatric Medicine, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi, China
| | - Ziping Shu
- Pulmonary and Critical Care Medicine Ward, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi, China
| | - Laodong Li
- Pulmonary and Critical Care Medicine Ward, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi, China
| | - Yu Zhong
- Department of Emergency, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi, China
| | - Weiqian Chen
- Department of Geriatric Medicine, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi, China
| | - Cunli Nong
- Department of Infectious Diseases, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi, China
| | - Jinliang Kong
- Pulmonary and Critical Care Medicine Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China;,Address correspondence to Jinliang Kong, The First Affiliated Hospital of Guangzi Medical University, Shuangyong Rd., Nanning, China 540000. E-mail:
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Kabir KI, John J, Satapathy AK, Sahu S, Behera B, Padhy BM. Oral Azithromycin Versus Doxycycline in the Treatment of Children With Uncomplicated Scrub Typhus: A Randomized Controlled Trial. Pediatr Infect Dis J 2022; 41:224-229. [PMID: 34966141 DOI: 10.1097/inf.0000000000003372] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To compare the efficacy of azithromycin versus doxycycline in treatment of children with uncomplicated scrub typhus in terms of percentage of children who attained remission of fever after 72 hours of administration of first dose of the study drug, mean time taken to attain fever defervescence, normalization of laboratory parameters, resolution of hepatosplenomegaly and lymphadenopathy. DESIGN Interventional, open-labeled randomized controlled trial. STUDY METHODS Patients admitted with undifferentiated fever in the In-Patient Department (IPD), Department of Paediatrics, All India Institute of Medical Sciences, Bhubaneswar, India, as per the inclusion criteria were randomized and was treated with azithromycin at 10 mg/kg/d in one group and doxycycline at 4.4 mg/kg/d for 5 days in the other group and was assessed based on the primary and secondary objectives. RESULTS There was no statistically significant difference between the percentage of children who attained remission of fever after 72 hours of administration of azithromycin (98.2%) and doxycycline (96.5%) (P value 0.47) and the average time taken for fever defervescence (azithromycin: 24.53 hours; doxycycline: 25.82 hours; P value 0.36). The odds of attaining fever remission in the doxycycline group as compared with the azithromycin group was 1.01 (95% confidence interval -0.60 to -1.71), which was also statistically not significant. There was less incidence of adverse drug events in the azithromycin group (1.78%) as compared with the doxycycline group (8.6%), which was statistically significant (P value 0.02). CONCLUSION Azithromycin is equally efficacious in terms of fever defervescence, resolution of clinical signs and laboratory parameters as doxycycline, is safer and better tolerated in children.
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Affiliation(s)
| | | | | | | | | | - Biswa Mohan Padhy
- Pharmacology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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Nabarro LE, McCann N, Herdman MT, Dugan C, Ladhani S, Patel D, Morris-Jones S, Balasegaram S, Heyderman RS, Brown M, Parry CM, Godbole G. British Infection Association Guidelines for the Diagnosis and Management of Enteric Fever in England. J Infect 2022; 84:469-489. [PMID: 35038438 DOI: 10.1016/j.jinf.2022.01.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/10/2021] [Accepted: 01/05/2022] [Indexed: 11/25/2022]
Abstract
Enteric fever (EF) is an infection caused by the bacteria called Salmonella Typhi or Paratyphi. Infection is acquired through swallowing contaminated food or water. Most EF in England occurs in people returning from South Asia and other places where EF is common; catching EF in England is rare. The main symptom is fever, but stomach pain, diarrhoea, muscle aches, rash and other symptoms may occur. EF is diagnosed by culturing the bacteria from blood and/or stool in a microbiology laboratory. EF usually responds well to antibiotic treatment. Depending on how unwell the individual is, antibiotics may be administered by mouth or by injection. Over the past several years, there has been an overall increase in resistance to antibiotics used to treat enteric fever, in all endemic areas. Additionally, since 2016, there has been an ongoing outbreak of drug-resistant EF in Pakistan. This infection is called extensively drug-resistant, or XDR, EF and only responds to a limited number of antibiotics. Occasionally individuals develop complications of EF including confusion, bleeding, a hole in the gut or an infection of the bones or elsewhere. Some people may continue to carry the bacteria in their stool for a longtime following treatment for the initial illness. These people may need treatment with a longer course of antibiotics to eradicate infection. Travellers can reduce their risk of acquiring EF by following safe food and water practices and by receiving the vaccine at least a few weeks before travel. These guidelines aim to help doctors do the correct tests and treat patients for enteric fever in England but may also be useful to doctors and public health professionals in other similar countries.
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Affiliation(s)
- L E Nabarro
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK; United Kingdom Health Security Agency, UK; St George's University Hospitals NHS Foundation Trust, London, UK; British Infection Association, UK
| | - N McCann
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - C Dugan
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK
| | - S Ladhani
- United Kingdom Health Security Agency, UK; Paediatric Infectious Diseases Research Group, St George's University, London, UK
| | - D Patel
- National Travel Health Network and Centre (NaTHNaC), UK
| | - S Morris-Jones
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - R S Heyderman
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK; Research Department of Infection, Division of Infection and Immunity, University College London, London, UK
| | - M Brown
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK; Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - C M Parry
- Liverpool School of Tropical Medicine, Liverpool, UK; Alder Hey Hospital and Liverpool University Hospitals, Liverpool, UK; Centre for Tropical Medicine and Global Health, University of Oxford, UK
| | - G Godbole
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK; United Kingdom Health Security Agency, UK; British Infection Association, UK.
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Park H, Lim Y, Kim MC, Kim SE, Jeong IS, Choi YD, Kim DM. Case Report: Fulminant Myocarditis Successfully Treated With Extracorporeal Membrane Oxygenation in Ikeda Strain Orientia tsutsugamushi Infection. Front Cardiovasc Med 2022; 8:795249. [PMID: 35004906 PMCID: PMC8727758 DOI: 10.3389/fcvm.2021.795249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 11/25/2021] [Indexed: 11/13/2022] Open
Abstract
Scrub typhus is an acute zoonotic febrile illness caused by Orientia tsutsugamushi having a specific geographic endemic area. This infection could be complicated with multi-organ involvement including myocarditis with variable severity. Here, we report a rare case of scrub typhus with biopsy-proven acute fulminant myocarditis which progressed very rapidly to cardiac arrest and was treated successfully with extracorporeal cardiopulmonary resuscitation. Clinicians should be alert to possible rapid progression of scrub typhus myocarditis to fulminant form and be prepared for close monitoring and temporary mechanical support if indicated.
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Affiliation(s)
- Hyejin Park
- Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Medical Hospital, Gwangju, South Korea
| | - Yongwhan Lim
- Department of Cardiovascular Medicine, Chonnam National University Medical School, Chonnam National University Medical Hospital, Gwangju, South Korea
| | - Min Chul Kim
- Department of Cardiovascular Medicine, Chonnam National University Medical School, Chonnam National University Medical Hospital, Gwangju, South Korea
| | - Seong Eun Kim
- Division of Infectious Disease, Department of Internal Medicine, Chonnam National University Medical School, Chonnam National University Medical Hospital, Gwangju, South Korea
| | - In-Seok Jeong
- Department of Cardiothoracic Surgery, Chonnam National University Medical School, Chonnam National University Medical Hospital, Gwangju, South Korea
| | - Yoo Duk Choi
- Department of Pathology, Chonnam National University Medical School, Gwangju, South Korea
| | - Dong-Min Kim
- Department of Internal Medicine, College of Medicine, Chosun University, Gwangju, South Korea
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Basharat Z, Akhtar U, Khan K, Alotaibi G, Jalal K, Abbas MN, Hayat A, Ahmad D, Hassan SS. Differential analysis of Orientia tsutsugamushi genomes for therapeutic target identification and possible intervention through natural product inhibitor screening. Comput Biol Med 2022; 141:105165. [PMID: 34973586 DOI: 10.1016/j.compbiomed.2021.105165] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/20/2021] [Accepted: 12/20/2021] [Indexed: 12/16/2022]
Abstract
Orientia tsutsugamushi (Ott) is a causative agent of scrub typhus, and one of the emerging pathogens that could affect a large human population. It is one of the misdiagnosed and under-reported, febrile illnesses that infects various body organs (skin, heart, lung, kidney, and brain). The control of this infection is hampered due to the lack of drugs or vaccine against it. This study was undertaken to identify potential drug targets from the core genome of Ott and investigate novel natural product inhibitors against them. Hence, the available genomes for 22 strains of Ott were downloaded from the PATRIC database, and pan-genomic analysis was performed. Only 202 genes were present in the core region. Among these, 94 were identified as essential, 32 non-homologous to humans, nine non-homologous to useful gut flora and a single gene dapD as a drug target. Product of this gene (2,3,4,5-tetrahydropyridine-2-carboxylate N-succinyltransferase) was modeled and docked against traditional Indian (Ayurvedic) and Chinese phytochemical libraries, with best hits selected for docking, based on multiple target-drug/s interactions and minimum energy scores. ADMET profiling and molecular dynamics simulation was performed for top three compounds from each library to assess the toxicity and stability, respectively. We presume that these compounds (ZINC8214635, ZINC32793028, ZINC08101133, ZINC85625167, ZINC06018678, and ZINC13377938) could be successful inhibitors of Ott. However, in-depth experimental and clinical research is needed for further validation.
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Affiliation(s)
- Zarrin Basharat
- Jamil-ur-Rahman Center for Genome Research, Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi, 75270, Pakistan.
| | - Umaima Akhtar
- Jamil-ur-Rahman Center for Genome Research, Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi, 75270, Pakistan
| | - Kanwal Khan
- Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Science, University of Karachi, Karachi, 75270, Pakistan
| | - Ghallab Alotaibi
- Department of Pharmaceutical Sciences, College of Pharmacy, Al-Dawadmi Campus, Shaqra University, Shaqra, 15571, Saudi Arabia
| | - Khurshid Jalal
- HEJ Research Institute of Chemistry International Center for Chemical and Biological Science University of Karachi, Karachi, 75270, Pakistan
| | - Muhammad Naseer Abbas
- Department of Pharmacy, Kohat University of Science and Technology, Kohat, 26000, Pakistan
| | - Ajmal Hayat
- Department of Pharmacy, Abdul Wali Khan University Mardan, 23200, Khyber Pakhtunkhwa, Pakistan
| | - Diyar Ahmad
- HEJ Research Institute of Chemistry International Center for Chemical and Biological Science University of Karachi, Karachi, 75270, Pakistan
| | - Syed Shah Hassan
- Jamil-ur-Rahman Center for Genome Research, Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi, 75270, Pakistan
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Khan I, Bahal P, Singh B, Priya P, Pandey R, Makkar A, Jindal A. Emergence of “urban scrub typhus” during Monsoon season in an urban pocket and biodiversity hotspot of New Delhi, India. JOURNAL OF MARINE MEDICAL SOCIETY 2022. [DOI: 10.4103/jmms.jmms_100_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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